Anger and dismay filled a Sydney courtroom on Thursday afternoon as the family and friends of David Dungay heard his case would be adjourned for almost one year.
The inquest was organised to run for two weeks, but by the end of Thursday there were still nine witnesses to appear, with only one day left.
“I am regretful that we couldn’t complete the matter by tomorrow,” said coroner Derek Lee.
In response to the announcement, family members reacted vocally, NITV News has been told, with Mr Dungay's nephew Paul Silva having to leave the court room.
Leetona Dungay, Mr Dungay’s mother, said she was devastated by the decision to delay the completion of the inquest.
“I hoped and prayed for closure from this inquest but now we have to wait another year in our fight for justice,” she said.
“The loss of our son did open up wounds, and now more wounds will be opened in another year's time.”
'Justice delayed is denied'
The family’s lawyer, George Newhouse, told NITV News what has been heard during these two weeks of the inquest was only the beginning.
“They wanted accountability, they wanted justice, and they wanted to know the truth about what happened to David and now all that is delayed for another 12 months,” he said.
“Justice delayed is justice denied.”
Many of Mr Dungay’s family are most distressed by the fact the staff involved in his death are continuing to work in the system.
Mr Silva told NITV News he is pessimistic anything will change. He believes it is likely there will be another black death in custody by the end of the year.
Mr Silva said he wanted to see those involved stepped down immediately, even if it is just until the inquest resumes next year.
“Someone has got to be held accountable. If it’s not charges, at least revoke the nurses' and doctors' medical licenses,” Mr Silva said.
“Let them not have a job. That should be enough punishment, it’s not what we want, but at least it’s something.”
The culture must change
The family has said they are going to use the time between now and June to keep black deaths in custody in the media spotlight.
Mr Dungay’s father, David Hill told NITV News there needs to be a change of culture in the justice system.
“They’re in their world where they think they can do what they please. It’s really hard to fathom what has happened to my son,” Mr Hill said.
He said there needs to be more Indigenous advocates and representatives in the prison system to assure people are supported and safe.
“They need people in the system that understand our culture and how to interact with us,” he said.
“That’s the problem, there’s not enough people working in there to help us.”
The inquest so far
Mr Dungay was just weeks away from release, when he died during a cell transfer at Long Bay jail hospital in December 2015.
He was held down by five prison officers after he was told to stop eating a packet of biscuits.
The court was played footage showing Mr Dungay transferred to the second cell while handcuffed and then injected with the sedative midazolam. Mr Dungay said 12 times that he couldn’t breathe.
The inquest found guards responding had no training or knowledge of positional asphyixia.
Corrective Services NSW announced at the inquest this week they will be introducing a new training course in the fatal risks of restraining someone face-down, the Guardian reports.
Assistant commissioner Kevin Corcoran told the inquest “we need to do something urgently”.
An expert medical witness also testified this week that there were multiple times during the restraint when a medically trained person could have noticed the warning signs, according to the Guardian, and ultimately stopped the onset of what he understood was a fatal cardiac arrest.
The inquest is set to resume in June 2019.