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The burnt down police station on Palm Island. |
Justified? Seeking answers in the death of Mulrunji
Issue 115 - 05 Oct 2006
ISSUE 115, October 5, 2006: Queensland’s Acting State Coroner, Christine Clements last week handed down her findings into the November 19, 2004 death of Palm Islander Mulrunji Doomadgee, which sparked a riot on the island. The coroner found that Mulrunji died in the watch house of the Palm Island police station at the hands of Senior Sergeant Chris Hurley, who allegedly struck Mulrunji so hard that he split Mulrunji’s liver in two. The purpose of a coronial inquest is to get answers to difficult questions. To assist the reader, we’ve presented much of the coroner’s findings in a ‘question and answer format’. The full, unedited transcript, which we urge you to read, is available from our website at www.nit. com.au/downloads
Who was Mulrunji Doomadgee
Acting State Coroner Christine Clements wrote: “The man known by his tribal name, Mulrunji, was thirty six years of age when he died. He was a fit, healthy man. He lived with his partner, Tracey Twaddle, on Palm Island. She was Mulrunji’s partner for some 10 years.
“She described him as having a positive outlook on life; proud to provide for his family and friends by his skills as a fisherman and hunter.
“He was not a trouble maker and had never been arrested on the Island.
“In her poignant statement to this court, [Ms Twaddle] said that she and Mulrunji looked forward to growing old together.”
Why was Mulrunji arrested?
The official reason was that Mulrunji was causing a public nuisance. But in truth he was arrested because he “mouthed off” to an Aboriginal police liaison officer as he walked past the scene of the arrest of another man (Patrick Bramwell) in a unrelated incident.
The coroner found: “Police Liaison Officer Lloyd Bengaroo told investigating police that Mulrunji had been walking past when Patrick Bramwell was being arrested. The two men knew each other.
“Mulrunji commented directly to Lloyd Bengaroo, challenging him as to why he should help lock up his own people. The indication was that Mulrunji was intoxicated. Lloyd advised him to walk down the road or he too would be locked up.
“When Snr Sgt Hurley got back in the car he asked Bengaroo what the person had said... When Bengaroo’s account was given, Hurley’s response was that he would lock [Mulrunji] up.
“The only additional “event” was that having walked off down Dee Street, Mulrunji turned and swore at the police officers. Snr Sgt Hurley then drove down to where Mulrunji was standing and arrested him.”
Should Mulrunji have been arrested?
The coroner found: “I do not determine the lawfulness of this decision but clearly the situation could easily have been addressed by means other than arrest.
“Snr Sgt Hurley was reliably told by his resident liaison officer the identity of the person and that he lived on the island.
“The fact that the senior serving officer did not know [Mulrunji] after two years on the island was an indication that he was not a troublemaker.
“It was completely unjustified to decide to arrest, particularly if that decision was solely influenced by a desire to check the computer for any outstanding warrants.
“That is not a basis for arrest.
“Given that Mulrunji had walked away and was clearly not impeding anyone there was always the discretion to do nothing or simply speak with Mulrunji.
“What is clear from the evidence is that Snr Sgt Hurley felt the need to exert his authority, ostensibly on behalf of the Police Liaison Officer who did not have direct authority to do more than warn Mulrunji.
“... Mulrunji had heeded the warning and walked on without further involving himself in proceedings. Despite Mulrunji’s protests he was arrested and told by Hurley that he was going to the watch house.”
The coroner later added: “It is a terrible tragedy that such a minor incident could lead to a man’s death in custody.”
The ‘fall up the step’
Snr Sgt Hurley told investigators on at least three occasions that when he and Mulrunji stumbled through the watch house door, he (Hurley) fell beside Mulrunji, not on top of him.
On one of those occasions, he re-enacted the scene for police, which had him landing on the floor on his knees beside Mulrunji.
“And you didn’t land on top of him?” asked one investigator. Hurley replied: “No, I landed beside him on the lino.”
How big was Mulrunji?
Mulrunji was “one hundred and eighty one centimetres tall and weighed seventy four kilos.”
How big is Snr Sgt Hurley?
He is “approximately the height of the watch house door frame. Snr Sgt Hurley himself informed the court that he was six foot seven inches tall (200.66 centimetres). His build was proportionate to that height.”
What happened after Mulrunji arrived at the watch house?
Mulrunji was arrested shortly after 10am. At 10:26am the Palm Island watch house log records Mulrunji was booked into custody for the offence of public nuisance.
The coroner found: “It is common ground that when Mulrunji was removed from the rear of the vehicle, Patrick Bramwell was still in the back of the cage area.
“Mulrunji was removed from the rear of the cage still protesting his arrest and detention and resisting being taken into the police station.
“There is no doubt he was uncooperative and indeed, that he struck out at Senior Sergeant Hurley with a back handed clenched fist, connecting with the police officer’s jaw.
“Senior Sergeant Hurley was clearly surprised at this action which was inconsistent with his experience of the response from Palm Islanders to his authority.”
Mulrunji was then bundled into the police station. As he and Snr Sgt Hurley entered, they tripped and fell through the doorway.
What happened inside the watch house?
Unbeknown to Snr Sgt Hurley, an Aboriginal man (Roy Bramwell, a relative of another Aboriginal man in custody) was seated inside the police station when they crashed to the floor. Mr Bramwell testified that he saw Snr Sgt Hurley “move his arm three times downward to Mulrunji as he lay on the floor in a punching motion”.
Mr Bramwell also testified that Snr Sgt Hurley was saying “You want more Mr Doomadgee, you want more? Have you had enough Mr Doomadgee?”
During the inquest, Snr Sgt Hurley responded: “The only possible explanation I can say for that, I did not punch Doomadgee, I was trying to raise Doomadgee off the floor using his shirt again but the shirt kept ripping.”
Mulrunji, who had stopped resisting Snr Sgt Hurley, was then dragged by the wrists to a police cell by Hurley and Sgt Michael Leafe.
What happened in the cells?
Mulrunji was left on the floor of the cell. Patrick Bramwell (who had been transported in the same police wagon as Mulrunji) was then brought in and placed in the same cell.
Snr Sgt Hurley testified that there was no sound from Mulrunji and that a check a short time later had him (and Mr Bramwell) asleep on the floor, snoring. A police video of the cell tells a different story.
The coroner found: “Patrick is clearly asleep and laying down on Mulrunji’s right hand side throughout the recording. When Mulrunji calls out for help and is writhing in pain, Patrick can be seen offering some comfort as he pats Mulrunji.”
The coroner also found: “Snr Sgt Hurley was asked if you could hear a prisoner in the cells calling out if you were in the station. He said you could, but that he did not hear Mulrunji call out from the cells that day.
“The images from the cell video tape of Mulrunji, writhing in pain as he lay dying on the cell floor, were shocking and terribly distressing to family and anyone who sat through that portion of the evidence.
“The sounds from the cell surveillance tape are unlikely to be forgotten by anyone who was in court and heard that tape played.
“There is clear evidence that this must have been able to be heard from the police station dayroom where the monitor was running.
“Indeed the timing of Senior Sergeant Hurley’s visit to the cell suggests that the sounds were heard.
“But the response was completely inadequate and offered no proper review of Mulrunji’s condition or call for medical attention. The inspections were cursory and dangerous even had Mulrunji been merely intoxicated. The so-called arousal technique of nudging Mulrunji with a foot is not appropriate. It cannot be sanctioned.”
Could Mulrunji have sustained his injuries before contact with police?
No. The coroner found: “This can quickly be discounted. Nothing from the various eye witness accounts of Mulrunji’s walk along Dee Street towards the Bramwell house, and on to the point where the police vehicle stopped and he was arrested, indicates that he was suffering from any injury at all, certainly not a life threatening abdominal bleed. Nor do any accounts of the arrest, from any of the witnesses, suggest the injury occurred in the course of the arrest. Mulrunji was still clearly in a physical condition to actively resist Snr Sgt Hurley and to throw a punch at the Sergeant at the watch house after he was removed from the vehicle. I find that Mulrunji was not suffering from an abdominal, or any other injury, prior to, or in the course of his arrest and transport to the Palm Island Police Station.”
The coroner also noted: “Associate Professor Stephen Lynch, who is a specialist general surgeon practising in the field of liver transplant surgery and treatment gave evidence. He discounted any physical possibility of Mulrunji having sustained the liver injury prior to the point of being removed from the police vehicle at the back of the police station. He said Mulrunji would not have been able to struggle, as the evidence suggests, if he had blood in his abdominal cavity at that time. His injuries must have occurred at the time of the fall or afterwards. This is again noteworthy because of the evidence that after the fall, and after Sergeant Leafe had returned from opening the cell door, Mulrunji was no longer resisting and required to be dragged to the cell.”
When did police realise Mulrunji was dead?
At 11:23am, less than an hour after Mulrunji arrived at the police station, a routine check by Sgt Leafe on the prisoners revealed Mulrunji had stopped breathing.
During the inquest, Snr Sgt Hurley indicated he thought Mulrunji may have still had a pulse, but then decided it was his (Hurley’s) own adrenalin rush.
Neither officer attempted CPR. Instead, an ambulance was called.
On the subsequent actions of Snr Sgt Hurley and Sgt Leafe the coroner wrote: “When there was serious doubt about Mulrunji’s health it was alarming to think that there was no-one who either had the skills, the medical or safety equipment or the inclination to implement an attempt at cardio pulmonary resuscitation. There was still uncertainty at that time that Mulrunji had died.”
Could Mulrunji have been saved after the assault?
No, he could not. An expert medical witness, Associate Professor Stephen Lynch, testified that Mulrunji’s injuries were so grave that “even if their true nature had been appreciated at the time, it would have been impossible to stabilise his condition sufficiently on Palm Island to allow safe transfer to Townsville, even if a doctor had been in attendance at the time of injury and had commenced resuscitation immediately.”
What injuries did Mulrunji suffer?
The coroner wrote: “The original autopsy examination of Mulrunji’s body was performed by forensic pathologist, Dr Guy Lampe. This occurred on 23 November 2004 at the Cairns Base Hospital mortuary.
“A second autopsy was performed in Brisbane on 30 November 2004 by Associate Professor David Ranson.
“Professor Anthony Ansford and Dr Byron Collins were also in attendance together with Dr Guy Lampe.
“The only external sign of injury was a small oval abrasion in the centre of the right eyebrow measuring 0.4 centimetres by 0.2 centimetres which was bleeding slightly.
“The right upper eyelid was swollen but there was no haemorrhage of the right eye.
“The second autopsy examined the right eye area below the skin surface. There was a small amount of (bruising.)
“The second autopsy also found some deep bruising immediately adjacent to the right side of the [jaw] and a small (3 centimetre) scalp contusion on the right... side of the scalp.
“Dr Lampe noted that there was no abrasion or boot or shoe impression on the anterior (front) abdominal wall, or the lower chest.
“The right-sided rib cage showed... fractures of four ribs, from the sixth to the ninth inclusively. There was no associated [bruising] of the muscle area above the fractured ribs, but there was some internal haemorrhage of the muscles above and adjacent to the eighth and ninth rib fractures.
“The most significant finding was in the peritoneal cavity. There was at least one and a half litres of blood and clot. The liver was virtually completely ruptured - “... cleaved in two” in Dr Lampe’s words.
“The two halves of the liver were only connected by some blood vessels.
“The portal vein had an oval hole... measuring 1.5 by 0.7 centimetres.
“There was [bleeding of the] pancreas.
“Both autopsies concluded that the cause of death was [internal bleeding], due to the ruptured liver and portal vein.
“The consensus of medical opinion was that severe compressive force applied to the upper abdomen, or possibly the lower chest, or both together, was required to have caused this injury.
“I accept that evidence and rely upon it in considering the evidence in this inquest to explain how this injury was caused to Mulrunji.
“All the expert medical evidence also concurred that a fall together, side-by-side, of the two men onto a flat surface was unlikely to have caused the injury that occurred.
“I accept that evidence.
“Medical witnesses were asked to consider whether the application of a knee or an elbow, whilst Mulrunji was on the hard flat surface, either during or separate to the fall could have caused the mechanism of injury. This was accepted as a possible means by which the injury could have occurred.
“Dr Lampe noted that the reported changes in Mulrunji’s behaviour from aggressive prior to the fall, to passive after the fall, suggests the events surrounding the fall are crucial.”
How was Mulrunji’s family informed of his death?
Mulrunji’s family became aware he had been arrested and arrived at the station later in the day to see him.
Police already knew Mulrunji was dead, but Snr Sgt Hurley did not tell the family, instead telling them to come back later in the day.
The coroner was scathing: “The most urgent consideration and advice should have been sought to properly, promptly and respectfully inform his family. If Senior Sergeant Hurley was not in a position to inform the family, then another police officer had to assume that responsibility.
“It is perhaps another indication that all was not well on Palm Island that the police were not in a position to immediately liaise with a local person of standing in the community to assist in speaking with the family in such difficult circumstances.”
A shoddy police investigation
Coroner Christine Clements was scathing on numerous fronts of the investigation by Queensland police into Mulrunji Doomadgee’s death.
“When interviewed by Inspectors Webber and Williams on 20 November 2004, Inspector Webber asked [Police liaison officer Lloyd] Bengaroo whether he was watching what happened after the fall. Bengaroo said, “No I wasn’t”. Inspector Webber asked, “What were you doing? What, how come you were standing there?” Bengaroo said, “I can’t remember. I just stood there because I was thinking, um, if I see something I might get into trouble myself or something. The family might harass me or something you know”. To which Inspector Webber merely responded, “Oh, OK.”
“How these senior investigating officers could have let that response remain unexplored was as wilfully blind as Bengaroo chose to be,” the coroner wrote.
Not up to RCIADC standards
The coroner also found the investigation into Mulrunji’s death failed to meet standards (set out in the Royal Commission into Aboriginal Deaths in Custody).
“The police officers initially appointed to undertake investigations were Detective Snr Sgt Raymond Kitching, from the Townsville Criminal Investigation Branch, and Detective Sergeant Darren Robinson, who was in charge of the Criminal Investigation Branch on Palm Island.
“They arrived on Palm Island on 19 November, the day Mulrunji died.
“On my understanding, neither was from the State Homicide Investigation Group.
“The form 1 report of the death was not forwarded to the State Coroner until the morning of 22 November 2004. It was signed by Detective Snr Sgt Kitching.
“The information failed to include any reference to the allegation of assault by Snr Sgt Hurley upon Mulrunji which had been made by Roy Bramwell to Detective Snr Sgt Kitching in his video interview on 20 November 2004. That crucial information was not available to the pathologist at the time of the first autopsy.
The role of the Aboriginal police liaison officer?
Police Liaison Officer Lloyd Bengaroo’s evidence was deemed “unreliable” by the coroner. However, the coroner added: “I feel some sympathy for Mr Bengaroo whose role was menial and without authority or apparent respect from either his own community or the Senior Officer in charge on the island.
“Indeed, Snr Sgt Hurley’s own evidence was somewhat disparaging of Lloyd.
“An inquiry was made about Lloyd’s access to information on the police computer system.
“Snr Sgt Hurley did not consider that Lloyd was authorised or that he had capacity to understand the system.
“The reality was that Police Liaison Officer Bengaroo was isolated from the police service and his own community both of whom, I have no doubt, he was trying to serve.
“However, torn between the two in an impossible role, he was emasculated and powerless to exert influence on the unfolding tragedy.
“As with many other witnesses, he had difficulty in giving his evidence in court and in making statements to investigating officers.
“His almost inarticulate responses and the reticence with which he gave his answers, was nevertheless informative.
“Mr Martin, SC assisting, submitted that Bengaroo’s answers could not be relied upon but I believe Bengaroo still provided valuable information to this inquest.
“He warned Mulrunji away when Mulrunji first spoke with him in Dee Street.
“He told Mulrunji that if he stayed he would be locked up. When interviewed by the police after Mulrunji’s death, his answers indicated he chose not to see too much in case it invited trouble with Mulrunji’s family.
“The inference I conclude from his evidence of what occurred at the police station is that he was careful not to see or intervene in a situation where he knew he had no power to influence what happened. His role only caused him distress and he felt he could do nothing without further risk of ridicule and censure from his own people.”
Mates investigating mates
The coroner wrote: “It was unwise and inappropriate for an officer serving on Palm Island, who was known to be a friend of Snr Sgt Hurley to be involved in the investigation.
“It was not the fault of Detective Robinson that this occurred - it was the responsibility of those appointing the investigators to recognise the perception of collusion that this might create. It was inappropriate for the officer most likely to be under investigation to be the person picking up the investigators from the airport.
“It was a serious error of judgement for the investigating team, including officers from ethical standards, to be sharing a meal at the home of that officer that evening. If a police officer needs support, it is not the task of investigators to provide this support, but to identify the need and delegate someone else to provide it.”
Comparing notes
The coroner wrote: “I have referred to various occasions when the investigation was compromised due to these compounding errors of lack of judgment.
“Snr Sgt Hurley clearly had the opportunity and did discuss the events under investigation with other witnesses, including Sergeant Leafe and Liaison Officer Bengaroo.
“Even after the Ethical Standards Officers (Webber and Williams) took over the investigation, they were party to an “off the record” discussion with Snr Sgt Hurley and Officers Robinson and Kitching about discrepancies in time.
“But this was not documented as part of the investigation by those officers; it only came to light incidentally through Snr Sgt Hurley’s answers to the CMC officer, Detective Inspector Webster.”
Enter the Crime and Misconduct Commission
The coroner wrote: “It has been abundantly clear that throughout this investigation, it was not until the Crime and Misconduct Commission assumed investigations, (on 24 November 2004) that there was any proper support or assistance provided to indigenous witnesses.
“Once the CMC took charge of the investigation, I am confident that it proceeded thoroughly, competently and impartially.
An unwilling witness
“The fourth interview [in a lengthy investigation] of Snr Sgt Hurley was conducted by Detective Inspector Webster and Detective Sergeant Britton from the Crime and Misconduct Commission. “It occurred on 8 December 2004 in Townsville with legal representation for the police officer. The interview commenced with a direction pursuant to Section 4.9 of the Police Service Administration Act 1990 which required him to answer all questions posed to him. This was the first occasion when Hurley had required the direction.”
On the Queensland Police Service’s attitude to the inquest...
“I note the Police Commissioner’s request via his counsel that they be permitted to make any further response on any proposed comments before these are made. Ample opportunity has already been provided when all parties were invited to make written submissions and an opportunity for reply was also given.
“I further note that the Police Commissioner’s legal representative was the only representative who chose not to avail himself of the opportunity to make final verbal closing submissions in court.
“It was an opportunity missed to address the family’s concerns from this State’s police service.
“In these circumstances I decline to give any further opportunity or create any further delay to permit the police to respond further on matters of general comment.”
On the Royal Commission...
“It is reprehensible that the detailed recommendations of the Royal Commission into Aboriginal Deaths in Custody should have to be referred to, so many years after the Royal Commission. The evidence is clear however that these recommendations are still apt and still ignored.”
A summary of the investigation
“It is reprehensible that the initial police investigations into the death were so obviously lacking in transparency, objectivity and independence.
“Even in a remote and isolated situation, the most important priority was to investigate the matter properly.
“It is regrettable that even in these proceedings some senior police officers have not been prepared to acknowledge the lack of sensitivity shown in the investigation and how it must damage public confidence.
“Until the challenge is accepted to work with the community towards a better relationship, the police are likely to remain in a very difficult working environment on Palm Island.
“This is regrettable, as I remain confident there are always possibilities for a better future to be realised for all the people living and working on a very beautiful island.”
Snr Sgt Hurley’s evidence at the inquest
The coroner wrote: “A direction was necessary to obtain Snr Sgt Hurley’s evidence on the basis that the answers may incriminate him. The public interest in the death in custody of an Indigenous man on Palm Island was sufficient to require his answers. According to law those answers are not admissible against Snr Sgt Hurley in any other proceedings except for the offence of perjury.”
The final word
The coroner ended the inquest with a message to the family of Mulrunji Doomadgee.
“Finally, to Mulrunji’s family, his partner Tracey, and his sisters, Jane, Elizabeth and Valmai, I extend my condolences for your loss. I hope this inquest has provided some answers.
“It is to be hoped that Mulrunji’s tragic death may yet lead to some positive changes and reduce the likelihood of similar deaths in custody.”
• A coroner’s findings, in brief
• The arrest of Mulrunji Doomadgee by Snr Sgt Hurley after he had “mouthed off” to another officer was “totally unjustified”. Mulrunji was warned by an Aboriginal police liaison officer involved in the arrest of another man (in an unrelated incident) to move on or face arrest. He did so, but was arrested minutes later anyway.
• After Mulrunji’s arrival at the police station, the Aboriginal police liaison officer “chose not to see too much in case it invited trouble with Mulrunji’s family”.
• Snr Sgt Hurley repeatedly claimed he and Mulrunji stumbled on a step and fell as they entered the police station but that he fell beside Mulrunji, not on top of him. He later accepted during the inquest that he may have fallen on Mulrunji.
• At the time of his death, Mulrunji was 181cm tall and weighed 74 kilos. Snr Sgt Hurley was six foot seven inches tall, with a body weight proportionate to his build.
• An Aboriginal man seated in the police station at the time (but unknown to Sgt Hurley) testified that while Mulrunji lay on the ground, he saw Snr Sgt Hurley “move his arm three times downward to Mulrunji as he lay on the floor in a punching motion”. Snr Sgt Hurley was saying, “You want more Mr Doomadgee, you want more? Have you had enough Mr Doomadgee?”
• In response Snr Sgt Hurley claimed he tried several times to lift Mulrunji from the ground by his shirt (which explained his apparent motion of striking Mulrunji while he was on the ground), but that Mulrunji’s shirt kept ripping.
• Mulrunji was then dragged by Snr Sgt Hurley and Sgt Michael Leafe to a cell.
• The alleged assault broke four of Mulrunji’s ribs, caused his pancreas to bleed, ruptured a vein to his liver and split the liver in half. Mulrunji also suffered trauma to the head and jaw.
• Despite testimony from Snr Sgt Hurley that Mulrunji slept soundly on the floor, closed circuit video of the cell reveals Mr Doomadgee “writhing in pain” on the floor of the cell and being comforted by another prisoner.
• Mulrunji’s cries for help, which were heard outside the police station and recorded by the video, were ignored by Snr Sgt Hurley.
• When it was discovered Mulrunji had stopped breathing, police did not attempt resuscitation, even though at one point Snr Sgt Hurley thought he felt a pulse.
• Mulrunji’s family arrived at the police station to visit him. They were not informed of his death. Instead, Snr Sgt Hurley told them to return later in the day.
• When detectives arrived to investigate the death, Snr Sgt Hurley picked them up from the airport.
• One of the detectives, Detective Sgt Darren Robinson, was “known to be a friend” of Snr Sgt Hurley. Both investigators had dinner at Snr Sgt Hurley’s home later that night.
• Snr Sgt Hurley discussed his evidence with other police at the station before the investigation process had been completed.
• The coroner found that some police detectives were “wilfully blind” in one aspect of the investigation.
• Snr Sgt Hurley gave evidence to the coronial inquest only because he was directed to - he did not voluntarily assist the inquiry. He also had to be directed to answer questions from the Crime and Misconduct Commission.
• Snr Sgt Hurley was found by the coroner to have been “untruthful” to the inquest on a number of occasions.
• In addition to Coroner Christine Clements findings, she handed down 40 recommendations. They can be read in the full, unedited transcript of the report which is available on the NIT website at www.nit.com.au/downloads.
 
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