In a four-part series, Michael Brull reviews the coroner’s report into the death of Ms Dhu, an Aboriginal woman jailed for unpaid fines who died in police custody after days of agony.
The best microcosm of the death of Ms Dhu, and the coroner’s report on her death, is the night before she died.
According to the police, not much happened. Then Senior Constable Nathan Nunn had the responsibility of lock-up keeper that night. He started his shift at 8:49 p.m.
At 12:26am on the morning of August 4, Nunn gave Ms Dhu two Panadol tablets. At 7am, then Constable Christopher Matier took over from Nunn. Nunn told Matier that Ms Dhu had been to Hedland Health Campus (HHC) twice, and both times had been declared fit for custody. Nunn told Matier that there was Panadol available for Ms Dhu if she needed it.
The coroner’s report more or less accepts that it was a quiet night. The coroner, Rosalinda Fogliani, does make some criticisms of Nunn. Specifically, she faults Nunn for leaving inadequate records. Specifically, Ms Dhu told Nunn that she had “sore bones”, and then he heard her moaning. Fogliani says that Nunn should have recorded those facts, and at handover Nunn should have informed Matier of Ms Dhu’s condition.
At another point in her report, Fogliani notes that Nunn didn’t take her complaints seriously. He claimed that “she wasn’t moaning when I went down there, until she saw that I was walking past her cell to do a check, and then she started moaning. But she didn’t say anything to me, and she saw me down there and looking.”
Fogliani notes that Nunn seemed to think that Ms Dhu “may have been feigning her symptoms”, and thus, her moaning was “not genuine”. Fogliani does not comment on the significance of this perception.
Now consider one incident that the coroner’s report mentions in passing. At 10:17 on the morning of August 4, Matier was caught on audio talking to an unnamed detainee.
“Matier: Has she been screaming all night?
Detainee: Yeah
Matier: … think she is trying to get out
Detainee: She’s really in pain.
Matier: Yeah.
Matier then “continues looking at some paperwork”. Fogliani comments that Matier seems to have “developed an indifference to Ms Dhu’s wellbeing”. That indifference “magnified” as the morning went on.
Yet Fogliani does not pursue what the detainee said. Had Ms Dhu been screaming all night long? Nunn admittedly ignored and refused to record her moaning when he heard it. Had he heard her screaming and decided it was all an act?
The coroner doesn’t pursue this question. The CCTV in the cells didn’t capture audio. The coroner doesn’t discuss whether Ms Dhu spent the whole night screaming.
Ms Dhu’s agony
Ms Dhu was brought into police custody around 5pm on August 2. She hadn’t paid some fines, and Western Australian police thought it would be a good idea to imprison her for being poor. She was only 22-years-old, dearly loved by her family. She was known as happy-go-lucky, and her family remember her as affectionate. She was a human being, and her life was precious.
Ms Dhu exited the police car and came into the police station with a strained walk, favouring one side. Aside from a broken toe and a foot blister, two of her ribs had been fractured by her partner in a domestic violence incident in April. She came in stoned from a “few cones”. Ms Dhu told the police about her injuries, and CCTV showed she walked with an “obvious gait”. But she declined to go to hospital.
Soon, the moaning began. Ms Dhu was in a lot of pain. When Constable Carrie Sharple asked her to rate her pain on a scale of 1 to 10, Ms Dhu said 10. An audio excerpt of their conversation is available at the Guardian. Ms Dhu sounds like she is in absolute agony.
Sharple asks: “What are the pains tonight? You weren’t in any pains before.” Ms Dhu moans “I’ve been in pain all day!” Then whimpers “I’ve been in pain all day.”
After 20 minutes of custody, Ms Dhu was in visible discomfort. Two hours later, she called for help, and pointed to the pain in her rib area. She was in anguish. Sharple believed her, and was probably the only police officer who actually did. Even she assumed that Dhu wasn’t previously in pain. The fact that Sharple, “by far the most inexperienced police officer” to interact with Ms Dhu, took Ms Dhu’s complaints seriously, whilst the experienced cops didn’t, tells us something important about the institutionalisation of racism among Australian police.
“You are a fucking junkie”
The case of Nunn is representative of the treatment of Ms Dhu generally. Ms Dhu may have spent the 10 hours of Nunn’s shift screaming. By his own admission, Nunn didn’t take her moaning seriously, and thought she was putting it on. By the time Matier’s shift came around, it was probably too late to save Ms Dhu.
At 7:35am, Ms Dhu started vomiting. She vomited repeatedly from 9-10. From 11:09, Ms Dhu tried sitting up, but couldn’t, and fell back, her head bashing the ground. At 11:23, she said her hands were blue or numb. The shift supervisor, then Sergeant Rick Bond, the most senior cop in the police station, inspected her and claimed “there was nothing that he observed of her that would suggest she needed urgent medical treatment”. The coroner noted that this was “incomprehensible”. Ms Dhu, by then, was in “an established state of septic shock”. Her health was so catastrophic at that point that even if she had received medical treatment, it was unlikely she could have been saved.
The police showed no interest in saving her. Sergeant Bond rejected two suggestions from Matier, at 9:54 and 10:28, which Ms Dhu be taken to hospital. When Senior Constable Shelly Burgess informed Bond that Ms Dhu said she couldn’t move her legs, he flew into a rage. Burgess went back to the cell. She roughly yanked Dhu’s arm, assuming that Dhu was just faking. Dhu fell back and bashed her head on the ground again. Burgess didn’t apologise, and didn’t check if Ms Dhu was harmed. Bond came by, and remained angry. The coroner reported that he admitted saying to her that “This will be the last time you go to hospital”.
In fact, he admitted he said “This is the last fucking time you’re going to hospital”. Calla Wahlquist, the outstanding Guardian journalist, reported on Burgess’s testimony.
Security footage shows Bond entering the cell, “moving Dhu into a sitting position and bending down over her, which Burgess said was to whisper in her ear… [Burgess] took Bond’s actions to mean he did not want his next comments to be recorded”. According to Burgess, Bond then said to Ms Dhu, “You are a fucking junkie, you have been to the hospital twice before, and this is not fucking on… you will fucking sit this out. We will take you to hospital but you are faking it”.
Fogliani did not include these alleged remarks in her report. She tended to only include claims about police that they themselves had more or less conceded. Bond denied these comments, but admitted telling other police officers she was a “junkie”.
The coroner settled for summarising the exchange as Bond “gesturing towards Ms Dhu’s prone body, in a clearly aggressive manner. He displayed an unprofessional attitude.” This kind of euphemistic summary is grossly inadequate.
Matier received a letter of warning, and was then promoted
The coroner does criticise three police officers for being “inhumane” and “unprofessional”. Most of them get a pass, or a minor tick of disapproval, like Nunn. Yet almost all of the police assumed that that Ms Dhu was lying or faking her pain, and treated her accordingly.
Nunn was later promoted to Detective Senior Constable, and Matier was later promoted to First Class Constable. Their contempt for Ms Dhu’s dignity was palpable. And the extent of their accountability will be some criticisms of Matier in a coroner’s report, and Nunn more or less escaping with a clean bill of health, other than failing to keep some records.
That, above all, is the story of Ms Dhu. Screaming all through the night, in unspeakable pain, slowly dying. And a smug cop ignoring her, assuming it was all an act, and later getting promoted. That tells you what you need to know about Aboriginal people and the criminal justice system in Australia.
Of all the police in the story, Burgess seems the only one to have suffered anything like consequences for her actions. She received a Warning Notice letter from the Assisting Commissioner, which “strongly questions your compassion, empathy and professionalism towards an ill detainee. Your actions in this regard significantly call into question your integrity, conduct, competence and professionalism”.
The warning means “any further breach could lead to a loss of confidence nomination and eventual sacking”. Bond and Matier also received those warning letters, though the coroner didn’t quote them. An Internal Affairs official conceded that none of them lost any rank or salary over what happened. Indeed, as seen, Matier was promoted.
Seven others received even more meaningless “corrective advice” letters.
Matier told the resuscitation team that Ms Dhu was faking
Some 20 minutes after Bond gestured in an “aggressive” manner at Ms Dhu, Burgess and Matier decided to take Ms Dhu to the hospital. Matier went into the cell and handcuffed her. Fogliani observed that “inexplicably”, he still thought “Ms Dhu was a flight risk. He still believed she was feigning her injuries”. He just went “through the motions, without any thought or regard for Ms Dhu”. He failed to apply any “common sense or common humanity”. Unconvinced that she couldn’t use her legs, he then dragged her across the cell floor. He claimed he did this “gently”.
Watching Ms Dhu’s vulnerable, incapacitated body being dragged along the floor is deeply disturbing. The coroner observed that Matier “appeared to not be consciously aware that he was dealing with another human being”.
Burgess then helped Matier carry Dhu to the police vehicle. Having waited 20 minutes to take her to hospital, it took about a minute to get there. Once out of the vehicle, Ms Dhu said, “I can’t move, I can’t move”. It had “no effect on him, and he did not display any sense of urgency”. Neither of them did.
He accepted that “his behaviour in conveying her into the hospital was with disregard to her fatal condition”. After they recklessly put Ms Dhu into the wheelchair, her neck dangerously hyperextended, they casually wheeled her in.
When Nurse Caroline Jones saw Ms Dhu, she flew into action, and the medical staff did their best to save Ms Dhu, to little avail. The coroner thought it likely that Ms Dhu had a cardiac arrest outside the hospital.
Matier was apparently unfazed. He told Jones that Ms Dhu was faking it. Uncuffing Ms Dhu for the sake of the medical team trying to save her, Matier even told the resuscitation team that Ms Dhu was feigning her illness. Seemingly nothing short of actually dying could shake Matier’s conviction that Ms Dhu was not to be trusted, and wasn’t actually sick.
Institutional racism
Why was Matier so convinced that Ms Dhu was not actually unwell? Part of the reason is that Ms Dhu had twice had medical clearance from the HHC, and deemed “fit to hold”. Another part of the reason is that his boss, Sergeant Bond, had told Matier and Burgess that Ms Dhu was a “junkie” who was faking her health problems. But why was this so much more compelling than what they actually saw of Ms Dhu?
Fogliani writes that “Mr Bond’s comments must have resonated with [their]own preconceptions concerning Ms Dhu”. In her report, she makes a singular reference to the possibility of police being influenced by racism. Having discussed the concept of institutional racism, she then applies it to the case of Ms Dhu:
I do not find that any of the HHC staff or police were motivated by conscious deliberations of racism in connection with their treatment of Ms Dhu, nor does Ms Dhu’s family make that submission. It is important to be clear on this point.
However, it would be naïve to deny the existence of societal patterns that lead to assumptions being formed in relation to Aboriginal persons. This is not a matter only for HHC, or its staff or the police. It is a community-wide issue and until there is a seismic shift in the understanding that is extended towards the plight of Aboriginal persons, the risk of unfounded assumptions being made without conscious deliberation continues, with the attendant risk of errors.
Ms Dhu’s Aboriginality is not the only reason police were suspicious of her. It is to be expected that police will be suspicious of all the people they detain.
Ms Dhu entered custody stoned, and admitted using illegal drugs. These are natural reasons for police to be suspicious of their detainee. But they were not merely suspicious. They didn’t just doubt what Ms Dhu said. They were unshakeably convinced that Ms Dhu was lying, and that her cries and moans and groans could be safely ignored.
It is hard to find a kind reason for how they could be so completely sure that Ms Dhu wasn’t really sick.
Thus, Ms Dhu’s last night alive is representative. She may have spent all night screaming. But they didn’t listen. Just like they ignored her moans and groans and cries, and assumed it was all an act, and nothing was really wrong.
It didn’t matter how terrible her health, how anguished her cries, how desperate her pleas. They knew she was faking. And so she died an unspeakably cruel death, taunted by the contempt of police who would never listen. And the cops who determinedly ignored her cries were promoted.
Part II of this series into the death of Ms Dhu – to be published later in the week – will focus on the performance of medical professionals.
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