The WA state coroner, Ros Fogliani, has just heard evidence of a sequence of indifferent and uncaring behaviour towards Ms Dhu in the second part of a four-week inquest into her death that ended on Thursday.
The family of Ms Dhu, whose first name is not published for cultural reasons, is hoping to find justice through the coronial process, but it is likely that they will be disappointed.
The limitations of the coroner’s role in WA will frustrate them, and the politics of ‘law and order’ mean that it is unlikely that any meaningful recommendations by the coroner will be followed.
The state government has failed for 25 years to fully implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody, which contain strategies that would have protected her, along with recommendations from other WA inquests such as the one into the tragic death of Mr Ward.
To make matters worse, in that quarter of a century the WA Government has knowingly introduced laws and policies that disregard or actively work against those recommendations.
Much time at the coronial inquest has been spent examining processes that failed Ms Dhu.
But in order to really understand Ms Dhu’s death one needs to understand the mundane and routine judgments, biases and assumptions that are made daily within the WA Department of Health and the WA Police Force.
"The state government has failed for 25 years to fully implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody."
In Ms Dhu’s case, despite suffering osteomyelitis, septicaemia and pneumonia, as heard at the inquest, some police, clinicians and health workers appear to have engaged in a negative feedback loop of disbelief that was conveyed back and forth from police to health workers and back again.
The coroner was told that at least some of this behaviour could be explained by heuristic thinking, a form of mental shortcut or cognitive bias, which may have led to the failures that ultimately killed Ms Dhu. But it is hard not to conclude that these are “weasel words” to obscure entrenched institutional racism, sexism and structural inequalities.
Some health experts have spoken to me about the concept of an ‘unworthy patient’ who is judged by clinicians and health workers (and there seems to be a similar concept in detention – that of an ‘unworthy detainee’).
Experts suggest that some patients are seen as less deserving by authorities because of their presentation, and that these concepts are ‘race blind’, suggesting that the mentally ill, the disabled and other shunned groups would be treated in the same miserable way.
It seems to me that racial prejudice is by far the largest subset of ‘unworthiness’, and that in pure numerical terms there are more Aboriginal people who fall into the ‘unworthy’ category than non-Aboriginal people, particularly in WA.
When combined with other forms of difference – gender, class or disability – any supposed unworthiness is compounded.
There will be many practical submissions made to the coroner about what could and should have been done to ensure that a victim of domestic violence does not die in circumstances such as Ms Dhu in the future.
"When combined with other forms of difference – gender, class, or disability – any supposed unworthiness is compounded."
However, it seems to me that the solution requires profound institutional and cultural change in the WA Police Force and the WA Health Service, and that change needs to starts with leadership.
Without criticising any individual, the issue of institutionalised racism must be addressed in a bipartisan way by the Premier, the Leader of the Opposition, the Chief Commissioner of Police and the Head of the Department of Health.
It has been 25 years since the Royal Commission into Aboriginal Deaths in Custody. It’s time for the Western Australia Government and its health and police services to draw a clean slate by making a fresh statement like that of David Morrison AO, the former head of the Army, to demand that any staff member or public servant with a prejudice against Aboriginal people should get out of the WA Police and WA Health services, and that there will be no tolerance for prejudice in those institutions.
They must also set new standards to ensure that a critical factor for promotion in both organisations must include the ability to show empathy and understanding of others, especially Aboriginal Australians.
Only then can we begin to heal the loss of Ms Dhu and avoid a tragedy like this from happening again.
George Newhouse is a director of the National Justice Project.