David Dungay inquest: NSW Corrective Services admit 'organisational failures'

NSW Corrective Services has spoken about the death of Indigenous man David Dungay.

David Dungays mother, Leetona Dungay on Monday.

David Dungays mother, Leetona Dungay on Monday. Source: AAP

NSW Corrective Services has apologised to the family of an Indigenous man who died in custody, admitting there were “organisational failures” that meant officers were not adequately trained before his death.

David Dungay died in Sydney’s Long Bay Prison Hospital on December 29, 2015 after five corrective services officers forcibly transferred the diabetic to a camera-monitored cell.

The 26-year-old diabetic had refused to stop eating a packet of crackers.

Harrowing footage played during a three-week-long coronial inquest showed Mr Dungay call out “I can’t breathe” a dozen times before going into cardiac arrest and dying.

On the final day of the hearing, Corrective Services NSW Assistant Commissioner Kevin Corcoran apologised to the family. 

Mr Cocoran conceded on Friday that it “did not train the officers in the Immediate Action Team at Long Bay in the risk factors for positional asphyxia.” 

“Corrective Services should have had procedures in place to ensure that we worked more closely with staff from Justice Health and Forensic Mental Health Network to recognise the risk factors for positional asphyxia.”

Also, “Corrective Services did not train our correctional officers to exhaust all the escalation techniques prior to entering cell 71.”

Mr Cocoran offered his condolences to the family: “We recognise that Mr Dungay’s death has deeply affected the family and that the pain they have experienced from his passing will continue well into the future.”

But for Mr Dungay’s family an apology is not enough.

Leetona Dungay
Leetona Dungay, mother of David Dungay, during the inquest. Source: AAP


“It’s one thing to change policy and procedures but another thing is accountability,” Paul Silva, Mr Dungay’s cousin, said outside of court.

“Someone needs to be charged - criminally charged - and held accountable.”

Family members were also given the opportunity to speak in court.

In an emotional testimony, Mr Dungay’s mother Leetona, supported by her children, read a statement in front of lawyers, the media and the public. 

“No mother should ever have to feel the pain of burying a son and watching him die begging to breathe,” she said.




“The whole world has seen the footage of David begging for life and saying he can’t breathe to his last gasp.”

“One minute my beautiful son was alive and healthy the next he was dead.” 

She questioned why Mr Dungay had to be moved to another cell even though earlier in the week the court heard he posed no immediate risk when he was eating the crackers.

“Why did they raid his cell?”

“I’m looking at all you men and women in the courtroom and asking you for someone to be held accountable for my son’s homicide.”

Supporters at the inquest.
Supporters at the inquest. Source: AAP


Mr Dungay’s sister and nephew also spoke in court, wiping away tears as they read poems Mr Dungay had written while in jail.

A statement from Mr Dungay’s father, David Hill, was read out by counsel assisting the coroner Jason Dowling.

“My son did his time for what he had done and did not deserve to pay the ultimate price with his life.”

Mr Dungay died just weeks after he was due to be released.

He had been convicted of robbery in company with wounding, aggravated attempted sexual intercourse and assault occasioning actual bodily harm.

Deputy Coroner Derek Lee will hand down his findings on August 23. 


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By Lydia Feng


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