CITATION: Inquest into the deaths of Kumanjay Presley, Kunmanara Coulthard and Kunmanara Brumby [2005] NTMC 086

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CITATION: Inquest into the deaths of Kumanjay Presley, Kunmanara Coulthard and Kunmanara Brumby [2005] NTMC 086

TITLE OF COURT: Coroner’s Court


FILE NO(s): A22/04, A49/04 and A54/04

DELIVERED ON: 10 October 2005

DELIVERED AT: Alice Springs

HEARING DATE(s): 9, 11-12 August 2005 - Alice Springs
10 August 2005 - Mutitjulu

FINDING OF: Greg Cavanagh SM

INQUEST –substance abuse (petrol), Aboriginal remote area communities, governmental responses thereto.

Assisting: Ms Helen Roberts
Northern Territory Government: Mr Tom Pauling QC
Ms Millie Coulthard, Ms Julie
Brumby: Ms Victoria Whitelaw
Aboriginal Justice Advisory
Committee “AJAC”: Mr Chris Howse

Judgment category classification: B
Judgement ID number: [2005] NTMC 086
Number of paragraphs: 70
Number of pages: 36


No. A22/04, A49/04 & A54/04
In the matter of an Inquest into the deaths of



(Delivered 10 October 2005)



1. The deaths of each of these three deceased were reported to the Coroner as they were unexpected, and unnatural deaths, coming within the definition of a ‘reportable death’ in section 12 of the Coroners Act (“the Act”). Each of the deaths occurred in very similar circumstances. Each deceased was an Aboriginal male living in a remote community in central Australia. The deceased in each case had gone to sleep with a container of petrol close to his nose and mouth, with blankets pulled up to cover his head. The following morning, each was found deceased by family members.

2. In the cases of these deaths, I have exercised my discretion pursuant to section 15 of the Act to hold a public Inquest in addition to the mandatory coronial investigation by police. Section 14(4) of the Act authorises the investigation of more than one death at one Inquest. I decided to hold a public Inquest for the following reasons (amongst others):

1. In my view it is in the public interest to reveal and highlight the extent of the sad and shocking petrol sniffing problems associated with these deaths and the many others that have occurred and are still occurring. I note that another death apparently resulting from petrol fume inhalation occurred at Mutitjulu subsequent to the close of evidence on 28 August 2005.

2. I wished to hear evidence about and examine the current programs and efforts dealing with the problem of petrol sniffing in the communities in which the deceased men lived (Willowra & Mutitjulu).

3. I wished to hear from the women of the relevant communities and country about their concerns in relation to the problem of petrol sniffing.

3. Counsel assisting me at this inquest was Ms Helen Roberts. I wish to place on record my appreciation of her efforts as counsel assisting me, including her efforts in travelling to Mutitjulu both before and after the inquest to communicate and convey information to residents about the coronial process. Other counsel sought and obtained leave to appear. Ms Whitelaw, of Central Australian Aboriginal Legal Aid Services appeared for the families of Kunmanara Brumby and Kunmanara Coulthard. Mr Tom Pauling QC, the NT Solicitor General appeared for the NT government and Mr Chris Howse appeared for the Aboriginal Justice Advisory Committee (“AJAC”).

4. Each of the three deaths was investigated by a police officer on behalf of the Coroner, and I had before me the coronial briefs containing statements and other material in relation to each of the deceased (Exhibits 6 – 8). I also had a number of statements, and submissions, produced to me during the period leading up to the holding of this inquest. Those included the statements of Northern Territory government witnesses (Exhibit 2) and of other persons and organisations who had relevant material to put before me (Exhibit 3). I will refer to many of those in the body of these findings. Also tendered were the medical files of each of Kunmanara Brumby and Coulthard (Exhibit 4,5) and other relevant documents.

5. I heard oral evidence from several witnesses. In Alice Springs, I heard oral evidence from Dr Terence Sinton, Superintendent Michael White, Constable Michael Deutrom, Mr Greg Andrews, Mr Blair McFarland, Mr Tristan Ray, Ms Vicki Gillick, Professor Peter D’Abbs and Ms Joanne Townsend. In Mutitjulu, I heard evidence from Ms Rene Kultitja, Mr Bob Randall, Ms Mary Turner, Ms Happy Reid, Ms Sarah Goodwin, Mr Michael Presley; and spoke with Ms Julie Brumby and Ms Millie Coulthard.

6. Ms Roberts, Ms Whitelaw and Mr Howse made oral submissions on the final day of the inquest. Mr Pauling QC has produced written submissions addressing the matters raised in those oral submissions and matters I raised during the course of the hearing.

7. In each case the investigation carried out by police on my behalf, into the immediate circumstances of the deaths, disclosed sufficient information for me to make formal findings as required by section 34 of the Act. Those findings are set out below. In addition to those findings, however, I have the power to comment on, and/or make recommendations on matters connected with the deaths.

8. In my view this Inquest may only deal with and examine matters and issues connected with the deaths in Willowra & Mutitjulu. My function is not to hold a wide ranging inquiry into the history, nature and extent of petrol sniffing in the Northern Territory. I have always been of the view that my function in holding any particular inquest is not to act as a de-facto royal commissioner commentating on and discussing issues and problems generally. Indeed the full court of the Supreme Court of the ACT in a major judgment concerning an ACT Coroner’s ongoing Inquest into bushfire deaths stated in The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors [2005] ACTSC 74:

[The Coroners Act]….“… does not authorise the coroner to conduct a wide-ranging inquiry akin to that of a Royal Commission….”
9. Furthermore, in Musumeci v Attorney-General of New South Wales (2003) 57 NSWLR 193 at 199, Ipp JA said:
“I think it sufficient to note, firstly, that it [An Inquest] is a hybrid process containing both adversarial and inquisitorial elements. Secondly, coroners exercise judicial power, notwithstanding the executive nature of their functions Thirdly, the proceedings in the Coroner’s Court involve the administration of justice:”
“The nature of an inquest differs from that of a fundamentally investigatory process such as a Royal Commission.”

10. With respect I agree. That it is not to say however, that I should be timid or narrow minded in my comments. However, it must be said that Government does not have to take notice of my comments or recommendations (as it appears not to have done with regard to some of Coroner Warren Donald’s recommendations in the last Inquest held in the Northern Territory concerning petrol sniffing (findings delivered at Alice Springs on 2 September 1998; ref. A82/94)).

11. Relevantly, it is to be noted that there have been numerous inquiries (bureaucratic, parliamentary and legal), reviews, assessments, consultant reports conducted and obtained over the past couple of decades concerning petrol sniffing. Many are referred to in the research report of Professor Peter D’Abbs and Ms Sarah MacLean, viz “Petrol Sniffing in Aboriginal Communities; A Review of Interventions” published in 2000. Indeed, the Northern Territory Parliament only in 2004 conducted such an inquiry which took place over several months (and looked at 18 submissions, held around 13 meetings and resulted in 17 specific recommendations).

12. Perhaps the most important and longest royal Commissions held in this country viz, Royal Commission into Aboriginal Deaths in Custody (‘RCIADIC’), amongst other things, looked into the problem of “petrol sniffing” and recommended (in 1991):

“Recommendation 238: That once programs and strategies for youth have been devised and agreed, after negotiation between government and appropriate Aboriginal organizations and communities, governments should provide resources for the employment and training of appropriate persons to ensure that the programs and strategies are successfully implemented at a local level. In making appointment of trainers preferences should be given to Aboriginal people with a proven record of being able to relate to, and influence, young people even thought such candidates may not have academic qualifications (page 84).
Recommendation 265: That as an immediate step towards overcoming the poorly developed level of mental health services for Aboriginal people priority should be given to complementing the training of psychiatrists and other non-Aboriginal mental health professionals with the development of a cadre of Aboriginal health workers with appropriate mental health training, as well as their general health worker training. The integration of the two groups, both in their training and in mental health service delivery, should receive close attention. In addition, resources should be allocated for the training and employment of Aboriginal mental health workers by Aboriginal heath services (page 91).
Recommendation 286: That the Commonwealth Government, in conjunction with the States and Territories Governments and non-government agencies, act to co-ordinate more effectively the policies, resources and programs in the area of petrol sniffing (page 94).

13. In 2002, the South Australian Coroner Wayne Chivell said in his findings relating to petrol sniffing deaths, about the Royal Commission recommendations (p76):

“12.2 It can be seen that simply by analysing the facts and circumstances of these three deaths, and the circumstances which still exist on the Anangu Pitjantjatjara Lands at the moment, those recommendations of the RCIADIC have not been complied with, either by Commonwealth or State Governments.
12.3 This is a great tragedy which I have no doubt will, if it is not addressed, lead to severe disability and further deaths, not to mention continuing social dislocation, crime, loss of culture and general community degradation and loss.”

14. This particular Inquest took evidence over only four days, with final submissions at the close of evidence on the fourth day. The relative brevity is explained by the fact that the problems leading to the deaths are manifest, well known and well researched. In my view, it was not necessary to duplicate the work of others and in particular that of my colleague the former South Australian Coroner Mr Wayne Chivell SM. With respect, Mr Chivell’s detailed findings and recommendations are recent, pragmatic and worthwhile and are especially relevant as they cover the same area, country and Aboriginal groupings as the Mutitjulu Community (albeit on the South Australian side of the border). Indeed, (sadly) I quote the coincidence between the opening paragraphs of Coroner Chivell’s 2002 findings and those of mine:

“1. This inquest concerns the deaths of three people, Kunmanara Ken who died on 3 August 1999, Kunmanara Hunt who died on 27 January 2001 and Kunmanara Thompson who died on 26 June 2001.
4. All three deceased died as a result of inhalation of petrol fumes. The mechanism of death was strikingly similar in each case, namely that the deceased took a can containing petrol to bed with them, and continued to sniff until they died from respiratory depression with a possible additional component of asphyxia.
5. Each person had marks on his or her face indicating that the head was resting on the tin, which had been shaped to fit the contours of the face and achieve a seal.
6. Each of them was a mature age (27, 25, 29 years) and each had been sniffing petrol for more than ten years, thereby justifying the description ‘chronic sniffers’. Each had led lives characterised by illness, hopelessness, violence and alienation from their families and community. Each had parents and family who did their best to stop them sniffing, and who have endured much suffering and grief as a result of their inability to do so, and the consequent death of a loved family member.


15. Section 34(1) of the Act details the matters that a Coroner is required to find during the course of an inquest into a death. The section provides:

“(1) A coroner investigating –

(a) a death shall, if possible, find –

(i) the identity of the deceased person;

(ii) the time and place of death;

(iii) the cause of death;

(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act; and

(v) any relevant circumstances concerning the death; or

(b) a disaster shall, if possible, find –

(i) the cause and origin of the disaster; and

(ii) the circumstances in which the disaster occurred.”

16. Section 34(2) of the Act operates to extend the Coroner's function as follows:

"(2) A coroner may comment on a matter, including public health or safety or the administration of justice, connected with the death or disaster being investigated."

17. The duties and discretions set out in subsections 34(1) and (2) are enlarged by s. 35 of the Act, which provides as follows:

“(1) A coroner may report to the Attorney-General on a death or disaster investigated by the coroner.

(2) A coroner may make recommendations to the Attorney-General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the coroner."

Formal findings concerning the death of Kumanjayi Presley

18. Pursuant to s. 34 of the Act I find, as a result of the evidence adduced at the Inquest the following:

(a) The identity of the deceased is Napthan Japanangka Presley, an Aboriginal male who was born at Alice Springs hospital on 8 February 1990.

(b) The date and place of death was 22 March 2004 at House 38, Willowra, NT.

(c) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(d) Particulars required to register the death are:

(1) The deceased was a male.

(2) The deceased was Napthan Japanangka Presley.

(3) The deceased was an Australian resident of Aboriginal origin.

(4) The death was reported to the Coroner.

(5) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(6) The Forensic Pathologist was Doctor Terence Sinton and he viewed the body after death.

(7) The deceased’s father was Alfie/Alby Presley.

(8) The deceased’s mother was Fenella Nagamara Warai Haines.

(9) The deceased lived in Ti Tree.

(10) The deceased had no usual occupation (he was a child).

Formal findings concerning the death of Kunmanara Coulthard

19. Pursuant to s. 34 of the Act I find, as a result of the evidence adduced at the Inquest the following:

(e) The identity of the deceased is Wallace Egan Coulthard, an Aboriginal male who was born at Alice Springs hospital on 13 March 1983.

(f) The date and place of death was 27 June 2004 at Lot 33, Mutitjulu, NT.

(g) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(h) Particulars required to register the death are:

(1) The deceased was a male.

(2) The deceased was Wallace Egan Coulthard.

(3) The deceased was an Australian resident of Aboriginal origin.

(4) The death was reported to the Coroner.

(i) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(1) The Forensic Pathologist was Doctor Terence Sinton and he viewed the body after death.

(2) The deceased’s father is Bryan Coulthard.

(3) The deceased’s mother is Millie Coulthard.

(4) The deceased lived in Mutitjulu in the Northern Territory.

(5) The deceased had no usual occupation.

Formal findings concerning the death of Kunmanara Brumby

20. Pursuant to s. 34 of the Act I find, as a result of the evidence adduced at the Inquest the following:

(j) The identity of the deceased is Trevor Milikins known as Trevor Brumby, an Aboriginal male who was born at Areyonga in the Northern Territory on 26 July 1967.

(k) The date and place of death was 8 July 2004 at Lot 84, Mutitjulu, NT.

(l) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(m) Particulars required to register the death are:

(1) The deceased was a male.

(2) The deceased was Trevor Brumby.

(3) The deceased was an Australian resident of Aboriginal origin.

(4) The death was reported to the Coroner.

(n) The cause of death was suffocation as a result of acute petrol vapour inhalation.

(1) The Forensic Pathologist was Doctor David Ranson and he viewed the body after death.

(2) The deceased’s father is Simon Tjuki.

(3) The deceased’s mother is Julie Brumby.

(4) The deceased lived in Mutitjulu in the Northern Territory.

(5) The deceased had no usual occupation.

Circumstances of the Death of Kumanjay Presley

21. Kumanjay Presley was only 14 years old when he died. The Friday prior to his death he travelled from Ti Tree to Willowra with his uncle and aunt; he had wanted to go, he said, to visit his father’s family. When they arrived, the teenager went to spend time at the Martin household, with boys around his age. It seemed that over the weekend he was able to come and go as he pleased between the two houses. On the Monday when the uncle went to leave he couldn’t be found. He had previously said he wanted to stay, and so the adults left without him. Everyone the police interviewed amongst his family and friends said they had never seen him sniff petrol and did not see him sniff petrol on any occasion prior to his death. Only the shopkeeper at Willowra community store saw him alone at about 6pm near the school grounds, sniffing petrol.

22. The following morning his grandmother, Molly Presley, found him in the back room of her house, deceased. He was lying with a clear bottle containing petrol covering his nose, with a blanket covering the bottle, pressed up against his face. The police further investigated the matter obtaining some information from the “Mt Theo Yuendumu” program. On the Saturday 20 March 2004 the Mt Theo supervisor and a worker went to Willowra to collect petrol sniffers to take to Mt Theo. On that day they questioned sniffers and community members regarding who was sniffing at Willowra. The deceased’s name was not reported to them.

23. On that day they took seven petrol sniffers to Mt Theo. The Mt Theo program, which is reportedly effective at Yuendumu, is funded primarily by the Commonwealth government with a Sport and Recreation grant from the NT government. It is assisted by the police and the clinics. In theory, there should have been no one in Willowra to encourage this boy to sniff petrol or to supply him petrol as the known sniffers had been taken to Mt Theo just two days before.

Circumstances of the Deaths of Kunmanara Coulthard and Kunmanara Brumby

24. Kunmanara Coulthard was born to parents Brian and Millie Coulthard on 13 March 1983. He had an older brother Roderick and a younger brother Neil. It appears from the evidence that he went to school until he was about 13 or 14 years old. The Court has been told that Millie Coulthard reports that before he started sniffing petrol, her son said to his father, “if you don’t stop drinking grog, we are going to start sniffing petrol”.

25. When he was 17 Kunmanara Coulthard he was flown to Adelaide hospital for treatment for burns to his face, chest upper limbs and with inhalation injury, after petrol he was sniffing ignited. He was so seriously injured he was intubated in the Intensive Care Unit for three days before being transferred to the burns unit. Again in August 2001 he suffered a full thickness burn injury to his right hand, requiring skin grafting. He spent eight weeks at Adelaide hospital and suffered ongoing significant stiffness and scarring of his hand which required physiotherapy. In her statement Millie Coulthard describes the circumstances of her son’s death:

“Kumana was a petrol sniffer for a long time. He always walked around holding a tin to his face sniffing petrol. Twice in years past he got hurt really bad from sniffing petrol. The first time he burnt his chest really badly and was flown to Adelaide for treatment because the fire went inside his nose and mouth. Second time he got burnt all over his right hand. I always use to tell him to stop sniffing but he wouldn’t listen to me. On Saturday just gone in the afternoon I had an argument with Kumana. He was upset with me because during the afternoon I was playing card with people for money next door to Happy Reid’s place. Kumana was standing beside me sniffing petrol from a can. He kept asking me for money so he could buy cool drink. I told him no because I only had $5. He was wearing dark coloured jeans, blue jumper and old sports shoes. He was mucking around and slapped me across the head because I did not have any money for him. After a while he walked away. At about 5pm I walked home. I don’t know where Kumana was then. I cooked supper at home and had a feed with my husband and Kumana who had showed up by then. It was dark when we had a feed but it was not really late. We ate some meat with tea and bread. I seen Kumana eat some food and drink some tea. After some time Brian and I went to sleep on the front porch of our house where we always sleep. Kumana said I’m going for a walk and went away for a while by himself heading along the bitumen road but it was dark and I cannot remember which way he went. It was about 8pm by this time. Later on that night my husband woke me up and said that Kumana was crying. On the porch was our mattress then a small camp fire then Kumana’s mattress. He was sitting up on his mattress sniffing petrol and crying. I asked him why are you crying? He said Mum I’m crying for you because I am sorry I had argument with you. He was thinking about when he hit me during the card game. I told him it was OK and that he should go to sleep. It was really cold that night. That was the last I spoke with him. Later that morning after the sun had come up, maybe 7am I woke up and saw him lying on his right side holding a tin against his face. He had a blanket over top of his body and wasn’t moving.”

26. His mother told Ms Whitelaw in conference some matters which I have accepted as evidence; one of those matters was that her son was depressed but had never been diagnosed with depression. I also note with concern that his medical notes do not record any attempts at treatment for petrol sniffing. There is no evidence in the brief to suggest that at any stage the deceased Kunmanara Coulthard or his family had sought or been offered any intervention or treatment in relation to this young man’s serious substance abuse problem which had resulted in serious injury on two occasions and which ultimately cost him his life. That his mother was helpless to help him appears obvious.

27. Kunmanara Brumby was born in Areyonga on 26 July 1967. During his adult life he lived generally between Docker River and Mutitjulu. His medical file at Mutitjulu Health Clinic records presentations for intermittent health problems such as chest, ear and skin infections from time to time. In December 2003 he presented with trouble breathing. His mother told the health worker he had been sniffing petrol all night in a small room. Statements of family and friends in the investigation brief make references to the effect that he was a chronic long term petrol sniffer.

28. Health worker notes from his Mutitjulu file and his Alice Springs file record that he was very quiet, uncommunicative and difficult to get a history from. Lack of English, and symptoms from his chronic ear infections were no doubt contributors to this, although Kunmanara Brumby was never tested for organic brain injury. In February 2004 he was discharged from Alice Springs Correctional Centre. Blair McFarland of the Central Australian Youth Link Up Service (“CAYLUS”) records in his submission how CAYLUS had some role in assisting Kunmanara Brumby to go to and stay at the Drug and Alcohol Services Association (“DASA”) Residential Rehabilitation Program in Alice Springs. He stayed for three and a half weeks. After that CAYLUS arranged for Kunmanara Brumby to go to Ilpurla outstation, a remote rehabilitation facility. Once Kunmanara Brumby returned from Ilpurla, he recommenced sniffing petrol.

29. Kunmanara Brumby slept in an abandoned car in the driveway of his mother’s house in Mutitjulu. His mother tried to look after him with food and keeping an eye on him. I am anxious that both mothers, Ms Coulthard and Mrs Brumby, have conveyed to them in the clearest possible terms that their sons’ deaths were not caused by some neglect that could have been remedied by them, (such as by being too cold or lacking food). To this end my Deputy Coroner shall be travelling to Mutitjulu this week to orally convey to them and to community members the contents of these findings. On the morning of his death Kunmanara Brumby was found in the car, with the windows closed, covered in blankets, with a tin of petrol near his head.


30. Sadly, as was revealed at this Inquest, witnesses (especially Aboriginal women) are getting tired of co-operating with inquiries about the problem including coronial Inquests with no result. Ms Vicki Gillick, the coordinator of the Ngaanyatjarra Pitjantjatjara Yankunytjatjara (“NPY”) Women’s Council Aboriginal Corporation attended this Inquest (with several senior Aboriginal women who had travelled from remote communities in the Northern Territory and South Australia); all anxious to help me. Relevantly, Ms Gillick gave evidence as follows, quote (transcript 12/08/2005 p.28):

“And essentially, importantly, I take it that the organisation provides a voice for Aboriginal women from the Central – from the Centre to – a voice for them to put forward their views?---It does. And some of the views that are put forward very strenuously and strongly by the women involve dealing with issues such as petrol sniffing and the supply of petrol, cannabis, grog running.”


“And one of the forums that the organisation has spoken is other coronial inquiries?---Yes, when I mentioned this coronial inquest in particular to Mrs Ward the immediate question that she raised was of course well we've had two in South Australia and what's happened? In 2002 the Women's Council executive initiated an inquest into three deaths and some of the deceased were related to the women who are now in the court. And then last year when Chivell SM decided to come back to the AP Lands and have another look at what had happened to his recommendations following other deaths the Women's Council was again very – separately and ably represented by Mr John Goetz, with an external grant that we acquired for that. So we made submissions, staff and executive members gave evidence and we put certain suggestions to Chivell SM.”

and further Ms Gillick states (transcript 12/08/2005 p.31):

“you know, 1998 since Donald SM made his recommendations about treatment centres and we're not very far advanced, save for the moves in South Australia to set up a rehabilitation but not a detox centre, which is still under discussion and we've only just let the contract for the cross border feasibility study to try to look at what's needed. And that's pretty pathetic after, you know, three coronial inquests really.”


“But, yes, apparently after these petrol sniffing inquests, including Donald SMs who made some specific recommendations about treatment centres, still haven't got them?---No, and I have now been put, in the last couple of years, twice in the position of having to explain to these women why – try to explain why, because they are very aware – we disseminated Chivell SMs recommendations twice now, translated by Linda Riv, and put them on radio, into newsletters and I'm constantly asked, well what's happened, what's happened? The coroner said all those good things, what's happened? And I'm having to make the explanation that your Worship just made, that the coroner is only in a position to make recommendations, he's not the government. He can't necessarily enforce those.”

31. The use of the word “pathetic” to describe Government responses to Coronial Recommendations in this area is that of the witness. Unfortunately, I cannot disagree with its use, although it must be said that the Federal and Northern Territory governments appear to have been making significant efforts in the past 18 months (or so) to come to grips with the problem. In particular, I commend the signing on 25 June 2005 of the Overarching Agreement on Indigenous Affairs, which sets out a five year commitment for the Commonwealth of Australia and the Northern Territory to work closely together in achieving better outcomes for Indigenous people in the Northern Territory.

32. After I adjourned the hearing at Mutitjulu I was taken for a drive around the community. I saw the sand dunes where some of the old people sleep, to avoid threats and assaults from petrol sniffers. I saw a number of houses which looked unsuitable for habitation and some which were boarded up, and apparently used by petrol sniffers. I saw a ‘car dump’ of several hundred rusted vehicles, within the grounds of the World Heritage listed Kata Tjuta National Park and within sight of Uluru, of which, it is said, much of the “gate money” flowing to the local Aboriginal community has financed. I saw the homes of contractors working in and near the community which had high protected fences and steel cages for garages (for obvious reason).

33. The distressing fact is that Aboriginal women, such as Sarah Goodwin who led her “petrol sniffing” son to me and pleaded for help, have a real and apparent sense of hopelessness. Despite much talk, usually in major centres much removed from her country, nothing much has happened to stop the sniffing. In this regard, I note that a politician in Darwin last month launched a 40 page (English language) education kit in an endeavour to address petrol-sniffing problems. In my view, such education kits are no answer to the pleas of persons such as Sarah Goodwin; people in her community are dying, or becoming brain damaged as we speak in front of anyone who wants to see. Their problems are immediate, stark and urgent. This should be recognised by more pragmatic endeavours addressing the evident realities of the present. In any event, the problem is about addicted young men from communities in which many of the people cannot read and write, and where English is a second language. Words of advice proffered thousands of kilometres away from the problem centres is what has been happening for many years without any apparent beneficial changes. Some women also complained of the failure of the Aboriginal men in their community to do anything. After three or four generations of petrol sniffing many of these men themselves are to addicted to substances (some petrol, some alcohol, some cannabis, some all three and more). The inability of “demand side” interventions such as print resources to have any effect in these circumstances was highlighted in the evidence of Greg Andrews (transcript 11/08/2005 p 6):

“..the social acceptability of participation in alcohol and drug and petrol abuse through consumption and supply, including supply for money but also including supply in exchange for sex, indicates that the decisive factor about substance abuse is that its actually become what I call a social epidemic in itself. Its an autocatalytic process. So the traditional demand side interventions like these [playing] cards that they delivered to the council the other day which say ‘Don’t drink too much”, these sort of things don’t work because the prevailing culture is one of says here ‘funded by the Australian government’. But these sort of things don’t work in addiction epidemic environments, particularly by themselves. And that’s why supply reduction is so critical. For example, through opal unleaded and also through stronger policing”.


34. On the issue of policing I do not propose to make extensive comments. Evidence was given by Superintendent Michael White about the positive changes that have come about at Kintore community since a police station was built there. Ms Gillick gave evidence about the importance of having sworn police officers in communities to reduce violence and trafficking of all types of drugs before other changes can successfully occur. I heard evidence that there is to be a permanent Police post built at Mutitjulu; the infrastructure to be funded by the Commonwealth government, and the ongoing operational costs (including Aboriginal Community police officers) by the Northern Territory government. I understand these plans are underway, and are welcomed by the mothers of the deceased (Ms Whitelaw’s clients), and by the Working Together Project partners which includes the NPY Women’s Council.

35. I pause to comment here on the work done by the Northern Territory Police force in investigating these deaths. Superintendent White has been of great assistance to me in obtaining additional material for my brief requested by Ms Roberts, and in facilitating her visits to Mutitjulu. Constable Michael Deutrom, of Yulara police station, conducted the investigation into one of these deaths, and gave thoughtful evidence before me about the day to day realities of policing the remote community of Mutitjulu. When at Mutitjulu I was able to observe the respectful yet appropriately friendly relationship between Constable Deutrom and community members, and vice versa. In my experience of nearly 25 years in the Northern Territory, this kind of relationship with NT police officers stationed in or near remote Aboriginal communities is not unusual and is to be commended.

Opal Fuel

36. The subject of Opal Fuel did not occupy much of the proceedings, as a “roll out” of Opal Fuel (unsniffable petrol) across the entire Central desert region was strongly supported by all parties at this inquest. I asked Ms Gillick about it (transcript 12/08/2005 p 32):

Well we believe it would be a good thing. I suppose in some ways this might get – this gets down to your philosophical view on whether supply reduction is worth trying and some people believe it's not – I heard a federal minister on the radio yesterday saying if it's not petrol it'll be glue, if it's not glue it'll be something else. But given the history of inhalant abuse and the generational devastation that's happening in the region, and that's the Northern Territory CAYLUS region as well as in our area, and the fact that the Commonwealth Government actually commissioned BP to create this fuel for the purpose of doing this, it would seem sensible to us that it is worth trying it. If you could somehow quarantine the area of unleaded fuel, yes, you'd still have the problem of cannabis, yes, you'd still have grog, but we also lobby constantly and persistently for the presence of sworn police in every major community as a way of intercepting trafficking. And in the end you've got to weigh up what are Aboriginal lives worth in this region.

37. Mr Andrews put to me that there were economic, moral and national interest arguments in favour of providing unsniffable fuel throughout the central desert regions. The economic argument is that while, on Mr Andrews’ calculations, the cost of rolling out the fuel could be about $8M per annum, the costs of doing nothing, in circumstances where there are an estimated 600 petrol sniffers across the region, will be much higher. That includes the health costs of maintaining an ex-sniffer with brain injury at about $200,000 per year. The moral arguments should hardly need stating. Although I do not hold Opal Fuel up as a panacea, the evidence is there that comprehensive coverage of the region with unsniffable fuel it is an available strategy which will substantially reduce petrol sniffing and its associated harms.

38. I note that Mr Chivell made similar comments in his 2005 findings. He said (paragraph 32):

While the development of ‘Opal Unleaded’ fuel is a welcome development, it should not be seen as a panacea for petrol sniffing. Action will be required to prevent the development of a black market in ‘sniffable’ petrol, and to develop adequate security measures to prevent theft of ....[sniffable fuel].

39. He went on to make a recommendation (paragraph 15):

That the Commonwealth government should continue to support the availability of ‘Opal Unleaded’ fuel on the Anangu Pitjantjatjara Lands, and consider what security measures will need to be taken when the constituents of ‘Avgas’ become unsniffable.

Treatment and Rehabilitation Facilities

40. Kunmanara Brumby was 37 years old when he died. Blair McFarland gave evidence that Kunmanara Brumby had at one time engaged with services in an attempt to stop sniffing petrol. However, this had ultimately proved unsuccessful. Mr McFarland stated that this was probably due primarily to the length of time he had been sniffing petrol, and the fact that once he went back to Mutitjulu the environment was exactly the same as when he left, with essentially nothing for him to do. The complexities and difficulties with dealing with long term petrol sniffers were starkly demonstrated to this inquest when Sarah Goodwin brought her adult son along to the inquest as I have already mentioned. When that occurred, nobody, including myself, lawyers, teachers, media representatives, police, and more particularly, local community men, did anything to take the can of petrol away from him, and this made me angry. The only effort was made by Greg Andrews who tried to persuade him to give up his petrol after I had adjourned the hearing. The implementation of the yet to be gazetted Volatile Substance Abuse Prevention Bill (NT) will empower police to take petrol from such sniffers, and to apprehend users and transport them to a ‘place of safety’.

41. Superintendent White expressed some concerns about the difficulty of identifying “places of safety” in remote communities, and the high possibility of police cells becoming those places. I share his concerns, as police cells are built to house criminals and not addicts per se. Moreover, I note with some alarm the evidence of Joanne Townsend (of the NT Department of Health and Community Services) in this regard when asked about it by Mr Pauling QC (transcript 12/08/2005 p62):
Okay, now under that legislation there's a power to take an affected person to a place of safety. But in the questioning in this inquiry some questioners referred to it as a safe place. There's a difference between the two concepts there. What is a place – what is intended by a place of safety?---The intent of the legislation is to allow police officers to make decisions around whether people need to be taken to a place of safety. (Inaudible) that would be taking them to home – to their homes or to another adult capable of providing care. In some instances where that person is at continued risk and where a judgment is made to take them to a place of safety then part of the community planning process will be to identify suitable places in the community. The legislation does include as option last resort including police cells and that's caused some consternation, but that decision was taken on the basis that in some communities that might be the last option. It's very clear that decisions around places of safety need to be made on a community by community basis.

Police cells in the centre of Australia are already mainly used to house drunks “for their own protection” (see inquest findings re Andrew Ross No.9806775, 9 February 1999). I hope they will not now be joined by petrol sniffers.

42. The new legislation will give powers to police not only to seize petrol, but to apprehend users and transport them to a ‘place of safety’ or to apply for court ordered mandatory treatment for chronic petrol sniffers. The legislation cannot commence until there are available treatment facilities for petrol sniffers. In 1998, Coroner Donald recommended, inter alia:

That the Commonwealth government establish and fund rehabilitation centres for chronic petrol sniffers in Alice Springs.

43. The Commonwealth government has not acted upon that recommendation. In the meantime, the sort of devastation and harm spoken about by witnesses in these proceedings and the South Australian inquests continues. Dr Sinton has practised as a forensic pathologist in the Northern Territory for about 7 years. He gave evidence in this inquest that over that time, he had performed autopsies in relation to “something in the order of maybe 50 to 60 cases of death where petrol sniffing is an associated event” (transcript 9/8/2005 p 30). When asked further questions about this he explained that he recalled about 5 or 6 cases where the deceased had died from asphyxiation as a direct result of petrol sniffing; and the balance from causes including trauma, long term clinical disease, or aspiration all with an indirect relationship to petrol sniffing.

44. In addition to these deaths, witnesses working in the field gave their estimate of the numbers of Aboriginal people in the region now suffering permanent organic brain damage as a result of sniffing petrol at 120 (11/08/2005 p29). Blair McFarland pointed out both the financial and human cost of caring for just one such individual is very high, giving an example (transcript 12/08/2005 p13):

“So like the petrol sniffer that Greg talked about who was down there listening to Bob Marley in a sort of, you know, wasteland, his twin brother lives five doors down from me. He’s in full 24 hour care and he’s the one that we think costs $250,000 a year to look after. You can hear him howling sometimes, howling from loneliness and sadness and he’s – but he’s a fit – his body is fit and they need two people on at night in case he gets upset because he’s incredibly strong and he gets upset and potentially dangerous. So he’s going to live a long time and each year they live its going to cost the community a quarter of a million dollars.”

45. Recommendations by Coroner Donald were also directed toward the Northern Territory government concerning the establishing of safe and appropriate rehabilitation and detoxification facilities. When asked by Mr Pauling QC about progress in respect of this recommendation, Ms Joanne Townsend told me that there had been recent moves to find facilities to support the legislation (transcript 12/8/2005 p60):

..... Now last year the NT Government committed money for an urban residential service based in Darwin – one based in Darwin and one based in Alice Springs. Those services – we believe that those services will need to be two separate services, one for adults and one for children. And we've recently gone to tender for that. That being said, there still remains some concerns from some stakeholders about the notion of us having specialised treatment facilities in this area. The other thing to note is that there are treatment options in the form of the drug and alcohol services that we already fund and in Alice Springs DASA has some beds, two, for people with sniffing problems and two for their family members to accompany them. And although CAAAPU have recently said that they won't be expanding their service to petrol sniffing they actually do have some clients with petrol sniffing problems in there.

All right, the request for tender you referred to is annexed to your statement and sets out what it is that currently is being sought by way of response from service providers. Is this aimed at service providers?---I’m sorry, what did you say, Tom?

With the tender that's exhibited to you affidavit or annexed to your affidavit, that is seeking service providers who say we can provide this particular service of a treatment program?---Yes. It's advertised as a public tender.

And when do tenders close, do you know?---They closed at the end of June, I think. I've written it down.

I'm looking at it, it says 6 July, I see?---6 July. Those tenders have not yet been – well there's been some assessment of them but it's not gone back through the procurement review board so – and (inaudible)not able to talk about them at this time.

46. Unfortunately in my view, words and promises of future action qualified by comments about just how difficult it is to achieve things in this area, (which was the tenor of some of Ms Townsend’s evidence) are not uncommon. Action in establishing rehabilitation and treatment facilities is necessary right now and I recommend such action.

Youth Services

47. Mr Tristan Ray, of CAYLUS, has worked closely with Willowra community. He put to me that Napthan Presley’s death could have been prevented if there had been a viable youth service in Willowra at the time, and explained it this way when questioned by Mr Pauling QC (transcript 12/8/05 p20):

“The death at Willowra how do you say it would have – would have been avoided if there’d been some youth program going? I mean do you know the background of what happened? --- Yeah very well. The Mount Theo Program services Willowra. Mount Theo is in many ways the stand up model of how a community has stood up and fixed petrol sniffing and in fact they’ve fixed it to the degree in Yuendumu that they’ve been able to start servicing neighbouring Walpiri communities and they service Willowra.

But this boy wasn’t a petrol sniffer?----He was sniffing petrol publicly in the community.

On that day? ----Yep.

But the people had been taken to Mount Theo the day before, had they not, the known sniffers?----The – what I would say is that with the program that’s there now sniffing has ceased in Willowra. They now maintain a zero tolerance policy on petrol sniffing, not to say that there aren’t occasional outbursts. So I think there would have been – people wouldn’t have just been resigned to seeing it. When they say it they would have had something to do, they would have gone and contacted a youth worker and – as they do now and action would have been taken. There would have been intervention.”

48. The evidence from CAYLUS was that there is now a youth service in Willowra, funded by the Territory government, which CAYLUS assisted in setting up and it is still assisting. Mr Ray made the point in evidence that the program consists of one salaried worker and not much more; and that the absence of additional support and resources leaves the existence of the service vulnerable. Hearing the evidence of workers in the field such as Mr McFarland, Mr Ray, Mr Andrews and Ms Gillick reminded all of us involved in this matter of the highly stressful conditions under which they work. To their credit, none of those witnesses spoke of difficulties facing them personally, but highlighted the lack of support for such workers living every day in the community. Ms Turner, the senior Aboriginal health worker at Mutitjulu, was under visible stress when she gave evidence and was clearly personally affected by two of the deaths the subject of these proceedings, as well as the devastation in the community caused by petrol sniffers. CAYLUS emphasised the vital role for youth workers in communities, pointing out that there is not even a single youth worker in the majority of remote communities. How can this be so, one might ask, when the Territory maintains through its counsel that “a great deal is being done in relation to youth services”.

49. At Mutitjulu I had the opportunity to hear evidence from Michael Presley, a Sport and Recreation Officer (Territory-funded) who has been at Mutitjulu for about six months. He was an impressive man, clearly committed to his position, and making positive changes in the community. And the evidence was clear that since his commencement there had been a significant decrease in property damage within the community, and an increased participation in sports. However, I also heard evidence that the position was not filled in Mutitjulu until the intervention and assistance of the Working Together Project. Mr Andrews gave evidence that it took six months for the Project to motivate the Council and to find a suitable person for the position, and he said this (TT 11/8/05 p13):

The fact that his position was empty for so long is an example of what you were talking about before when you asked me about money and I’m sorry I felt that I didn’t answer that question properly. But the resources, the financial resources are there for this position to be filled. It was just that the council wasn’t capable of recruiting him and most members of the council are banned from Yulara [Outback Pioneer Hotel] for drinking, some of them are in gaol, and most of them are men who drink regularly.

50. That answer above raises a number of issues, but the comments about the inability of the community council to utilise available government funding for a position is also applicable to Willowra. The submission put in by CAYLUS sets out the history of the breakdown of community governance in Willowra, and how that impacted upon such matters as the absence of a youth worker, or sport and recreation officer (as well as the absence of many services which one would consider basic and essential services).

51. Ms Gillick also made reference to this issue in her evidence. She said (transcript 12/8/05 p29):

We often say the Women’s Council believes these issues are not just about money, but they’re about ideas and policy and so forth. So if you have South Australian government, for example, deciding to employ youth workers or to initially decide to employ youth workers and then deciding that those youth workers should be employed by a community council which clearly has no experience or capacity to support or supervise, and they insist on employing local, untrained, young Anangu or Aboriginal youth workers then its a recipe for not much happening. And that’s the sort of thing that’s happened.

52. While Ms Gillick said that the Women’s Council did not take the position that having youth workers would solve all the problems, she said that their services were important, and that the worker needed to have particular skills and to be a person of integrity (transcript 12/8/05 p30):

And the other things, for example, schools don’t – community councils don’t employ school teachers. Why would you have a dysfunctional or not very experienced community council employ a youth worker in a community who needs a high level of skills and is dealing with, you know, difficult kids in difficult circumstances?

MS ROBERTS So you wouldn’t agree with the model of having funding provided to the community council to employ the youth worker? ----Well I wouldn’t say that it’s never going to work but I do think that where the Women’s Council has taken on in the last 10 or more years a lot of the work that government would normally do in an urban or rural or even regional setting I think there has to be a role really for the State to provide some services and to ensure that those services are delivered. And I think that the state that a lot of our communities are at, that that is a role that should be taken on by government to also ensure that its done, that there’s some accountability.

53. The policy response behind this approach – that is, providing short term funding to community councils to provide services such as youth services – has been commented on by Professor Peter D’Abbs in a number of published papers. In evidence he said this (transcript 12/8/05 p47):

I think one of the main factors up until very recently has been (inaudible) position that the governments, both Commonwealth and State and Territory governments have adopted where they’ve said this is really a community problem and the community has to take ownership. Now I don’t want to go too much into this, except that I think it can be traced back to probably to 1985 at least when there was a very detailed and thorough Senate inquiry into petrol sniffing and other volatile substance misuse. And I think it was probably in many cases this was a peculiar reading of the notion of self-determination. But whatever the motives the outcome of this particular stance has been that governments have really not attempted to develop a coherent policy toward petrol sniffing or other volatile substance misuse. They have not committed resources, substantial resources to addressing it, but instead they’ve given generally very short term funding to non-government organisations and in some cases community organisations but in doing so what they haven’t done they have not provided continuity of funding to those programs or services that appear to be successful. Indeed they’ve made no efforts to evaluate programs so in fact we don’t know which ones have been successful or not successful and they also made very little effort to look at what kind of support services government itself should be providing to enable these community based services to work effectively.

54. Professor D’Abbs went on to qualify his remarks and clarify that in his view there has been a shift in recent times in the approach of the Territory government. He, however, made it clear in response to further questions from Mr Howse, that a position in which communities are left largely to themselves to meet needs such as education, recreation and employment opportunities, is clearly untenable. I pause to note that it remains unsatisfactory even when monies are simply advanced to remote community councils to meet such needs without adequate professional help.

55. The Territory has submitted through Mr Pauling QC, that youth services only form “part of the multifaceted approach required to address the issue [of petrol sniffing]”. While that may be the case, youth services are still vital. It has been put to me by an academic commentator as well as by the people working “on the ground” that an approach which is heavily reliant upon a functioning community council structure to apply for funding, recruit, and support a youth services worker, is an inadequate approach. Willowra has only been able to do it with the assistance of CAYLUS, and Mutitjulu with the assistance of the Working Together Project, over time.

56. There is no present proposal to alter this model of service provision. The Territory has submitted that it is “committed to joint and shared responsibility of the issue together with the community, government and non-government organisations”. At a greater level of detail, Mr Howse referred to attachments to the statement of Ms Joanne Townsend, being Territory strategies for addressing inhalant substance abuse. Mr Howse quoted a portion of the strategies document and then put these questions to Ms Townsend (transcript 12/8/05 p74):

MR HOWSE Now what those two principles and that statement from document T2, when synthesised, actually suggest is this direction, I put to you. Its up to the community to take responsibility to consider in the first place what kinds of sanctions against petrol sniffing ought to be brought to bear; would that be a fair summation?---Yes

And its also the communities responsibility to promote meaningful diversions for young people which include education, recreation and employment opportunities; that’s obviously also there, isn’t it?—Yes.

Now it is a fact that many of the communities on which petrol sniffing is a major phenomenon are communities pretty much split apart and dysfunction; would you agree with that? ---Yes where there’s a high proportion of sniffing that is a fact.


Okay. Now going back to your department’s strategy, how can a community which is split apart and dysfunctional in its manner of governance be expected to take responsibility for diverting young people in a meaningful way when considering education, recreation and actual employment opportunities, how can a community be expected to do that? -----I think the Working Together project is evidence that that community isn’t expected to do that without significant support and guidance from a range of players.

57. Mr Pauling QC has submitted that any recognition that youth services should be an essential service is not open to me on the evidence, and is beyond the scope and nature of the inquest. I do not agree. I have heard essentially the same evidence from every witness about the importance of adequately resourced, adequately supported, properly skilled, youth workers in communities. It has a direct impact upon the quality of life for young people, in providing diversionary activities and a consequential impact upon education and health.

The Working Together Project

58. The Working Together Project is an excellent and commendable initiative. It has achieved a number of significant gains and made positive steps forward in Mutitjulu. Some of those include establishing a childcare centre which has provided a safe place for children, and employment for local young women; recruitment of a youth worker; obtaining funding for a substance abuse worker. Future goals include having women on the Council, and continuing to develop good governance strategies so that community members can make decisions about such things as tenancy agreements and school attendance. Greg Andrews was asked by Mr Pauling QC (at transcript 11/08/2005 p20):

Would you describe the council’s decision to reopen the child care centre as something proactive from them?------I think to be honest without the CEO and me encouraging the council they wouldn’t have reopened it. So I would say it wasn’t proactive. But what I would say is the council is becoming more proactive than it was a year ago. And maybe an example of something that they have been proactive in, if I may. When I arrived in Mutitjulu there was either denial – there was 80% of people were in denial about the addiction epidemic and 20% were talking about it. And 90% of the people were in denial about the child abuse that was going on. But now people have actually moved along a spectrum from denial to recognition and now they're starting to take small steps that are proactive. And so just around Easter time the council made a decision, which I think was proactive, and started issuing trespass notices to petrol sniffers who didn’t belong in Mutitjulu. And that's not addressing the children like Max and like Kenny, who belong in Mutitjulu, but it is a first step. It's a first step in an incremental process where they've actually started to be proactive and acknowledge that it's a problem, not just talk about it or ignore it.

59. In the answer above, and in many others, Mr Andrews stressed that the progress would be slow and incremental, and it must be if it is to be sustainable. When asked about the continuation of funding for the project, he answered that he had been given an unofficial indication that government is willing to recommit to the project for three to five years. I would be surprised to hear otherwise, given that it is a Project with the potential to make a real difference, in a sustainable way, to this remote community, and one hopes others in the future. While I commend all Project partners for their commitment and efforts, I must say that I have rarely met a more qualified, committed and emotionally and culturally supportive advisor in terms of Aboriginal substance abuse problems than Mr Andrews. His work is simply outstanding.

60. This Inquest and some of the problems that I encountered at Mutitjulu in particular, is similar to another Inquest carried out by me in 1998 into multiple deaths at a remote Aboriginal community in the Northern Territory, viz. Tiwi Islands. That particular community was not dysfunctional in terms of governance, however, many of its young men were committing suicide at an horrendous rate. The evidence at that Inquest revealed high levels of alcohol and cannabis abuse, indeed, I found that such abuse was a direct causal factor. I found that substance abuse went “hand in hand” with youth of the community becoming frustrated and confused by:
“problems such as unfulfilled potential, frustrated ambition, boredom, unemployment and non-achievement in terms of career aspirations …..”

61. It must not be forgotten that in remote communities, Aboriginal youth do not live in a pristine traditional environment with their culture untouched by urban influences. They watch TV and videos, follow the same sporting teams as do city dwellers. Yet they live in remote communities, trying to reconcile elements of traditional culture with influences alien to their culture.

62. In those findings, I quoted Mr Justice Muirhead (former Territory Supreme Court Judge, Federal Court Judge and the first appointed Royal Commissioner into Aboriginal Deaths in Custody):

“A very wise judge once said in relation to Aboriginal youth in the Northern Territory:-

“…in dealing with Aboriginal children one must not overlook the tremendous social problems they face. They are growing up in an environment of confusion. They see many of their people beset with the problems of alcohol, they sense conflict and dilemma when they find the strict but community-based cultural traditions of their people, their customs and philosophies set in competition with the more tempting short-term inducements of our society.

In short the young Aboriginal is a child who requires tremendous care and attention, much thought, much consideration.”

(Jabaltjarl v Hammersley (1977) 15 ALR 94 (NT) Muirhead J (at 98).)”

63. This cultural confusion needs to be recognised before successful attempts are made to address substance abuse problems such as petrol sniffing. Furthermore, the very fact of the remoteness of the communities and their isolation needs to be recognised; words such as “the tyranny of distance” are apt in this context. That is to say, most aboriginal communities just do not have the community facilities that city, suburban and provincial communities possess for their disaffected and bored youth such as swimming pools, sporting ovals, recreational parks, community halls, rehabilitation centres, drug and alcohol counsellors, youth centres, training facilities, job search help, selection of different schools, medico / legal help, police stations; some have some, some do not. Furthermore, some have some of these physical assets, but no personnel (or qualified personnel) to assist, direct and coordinate the appropriate use of same.

64. When indigenous disadvantage and cultural confusion are added together with, (a) the lack of physical and human resources as described, (b) the complete break down of community governance and discipline, (c) decades of community petrol sniffing abuse which is (now) cross generational, in my view, it is simplistic in the extreme to suggest that the answer to the problems of petrol sniffing is for the addicts and their communities to help themselves. That is to say, the horrors of present day Mutitjulu (and other remote communities) are not sensibly addressed by peddling the myth that such disadvantaged citizens might simply help themselves and solve the problem. They and their families are not able to do so by themselves.

65. I quote from the Summary of Mr Chivell’s findings in 2002:

2. Petrol sniffing is endemic on the Anangu Pitjantjatjara Lands. It has caused and continues to cause devastating harm to the community, including approximately 35 deaths in the last 20 years in a population of between 2,000 and 2,500. Serious disability, crime, cultural breakdown and general grief and misery are also consequences.


10 Many attempts over the years to combat petrol sniffing have been unsuccessful. Anangu continue to try and care for sniffers even when they continue to sniff, and even after they are violent and disruptive to their families and the community. Some Anangu are concerned that if they try and stop sniffers they will harm them, or that the sniffers may harm themselves. They look to the broader community to help them deal with a problem which has no precedent in traditional culture.
A variety of intervention strategies to combat petrol sniffing were analysed at this inquest. Clearly a successful strategy must have broad community support.
Strategies at three different levels are called for:

Primary interventions – to reduce recruitment into substance abuse;

Secondary interventions – seeking to achieve abstinence and rehabilitation;

Tertiary intervention – providing services to the permanently disabled.

Strategies include:

Youth activities through provision of youth workers;

Neuropsychological testing;



Legal sanctions;

Night patrols;

Programmes for ‘Children At Risk’;

Disability services;

Secure care facilities;


Crime Prevention strategies;

The implementation of any one of those strategies by itself is likely to fail, but introduction in combination with a variety of others will give a better chance of success.
All these strategies must be accompanied by strategies to address socio-economic issues such as poverty, hunger, health, education and employment.
The implementation of these strategies will doubtless involve difficult problems such as recruitment and retention of suitable staff. Creative solutions will need to be found. Anangu cannot be expected to find all of the human and other resources to tackle their problems. They need the assistance and input of non-Anangu professional people to tackle these problems directly, and to give them the power and skills to take up the task in due course”

66. I recommend that the Australian and Northern Territory governments closely examine, consider and adopt (where applicable) his recommendations in relation to the Northern Territory side of the border. In any event, the Northern Territory government has for consideration and use its own recent parliamentary committee report with recommendations which, in my view it ought to implement as soon as possible.

67. In addition, I further recommend as follows:

1. I recommend that the Northern Territory government ensure that suitably qualified youth workers, including sport and recreation officers, be recruited and located in remote Aboriginal communities and, in my view, such workers ought be vetted and selected by professional agencies. Those workers should be assisted by appropriate conditions and remuneration, and direct access to a support network and necessary respite, to ensure (as far as possible) their ability to remain working in the community for a reasonable period of time. I note, by way of example, the “remote area incentives” awarded to Northern Territory Police.

2. I recommend that the Commonwealth government support the universal “roll out” of Opal Fuel across the entire Central desert region, for the reasons and with the qualifications already mentioned herein.

3. I recommend that the Commonwealth and Northern Territory governments recommit to the Mutitjulu Working Together Project for the long term. Further I recommend there be an evaluation of the Project, and that on the basis of that evaluation, consideration be given to implementation of a similar Project in other communities if appropriate.

4. I recommend, as has been repeatedly recommended by Coroners at least since 1998, that immediate action be taken by governments to establish and adequately resource treatment and rehabilitation facilities suitable for petrol sniffers in the centre of Australia.


68. Only this year on 14 March 2005, Coroner Chivell, in yet another Inquest into petrol sniffing deaths stated, after lamenting the slow governmental reaction to his 2002 recommendations (paragraph 20):

“I referred to a variety of socio-economic factors including poverty, hunger, illness, low education levels, unemployment, boredom, and feelings of hopelessness in findings I wrote following inquests conducted in 2002 into the deaths of three people on the Anangu Pitjantjatjara Lands resulting from petrol sniffing. I commented:

‘That such conditions should exist among a group of people defined by race in the 21st century in a developed nation like Australia is a disgrace and should shame us all.’
These conditions still exist.”

69. I am driven to add that the shocking scenes that I saw at Mutitjulu confirm that this is so.

70. Finally in my view, expensive as it may be, we must realise that if we are to continue to be enriched by traditional Aboriginal culture as exists in remote communities in the centre of Australia, then government must resource these communities so that they function properly and their members live in good health with the dignity to which all citizens are entitled.

Dated this 10th day of October 2005.