Eighteen months after his 21-year-old son was found dead in his prison cell at John Morony Correctional Centre in Windsor, Terry Griffiths is still waiting for the Department of Corrective Services to return his phone calls.

Griffiths’s son, also called Terry, was serving a six-month sentence for property and personal violence offences, and awaiting sentencing on other charges involving arson. On December 3, 2009 — one day before he was due for sentencing and a month before he was due for release — the young Aboriginal man was found hanging in his single-person cell.

“You know, I thought they’d ring and let me know what the circumstances were and everything [but] … We didn’t actually get anything from Corrective Services. No phone calls, no correspondence, not anything. Even now, nothing,” says Griffiths.

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“I tried to ring the jail but I can’t seem to get through to anyone or [get] anyone to ring me back. I rang up and spoke to the receptionist and asked could I talk to someone in regards to what happened with Terry. They said they’d pass it on to somebody and then I hear nothing,” he says.

“[I’ve called] three times now.”

According to his father, the energetic but cheeky Aboriginal kid from Inverell had been diagnosed with schizophrenia several years before being locked up. Griffiths says Terry was moved at least three times between various prisons and Long Bay prison hospital — a process his son found extremely frustrating. Each time he was moved, his care was disrupted, he was from friends and other support people in prison, and his phone account authorisation was erased, making it difficult to contact the family, his father says.

“He was a happy-go-lucky boy, used to talk up a lot, muck around, play around. But when he went to prison, every time I seen him he was just more and more withdrawn,” Griffiths says.

As weeks became months and the months slipped away, Griffiths watched his son’s condition deteriorate. The father of five, including Terry, grew increasingly anxious but says he just didn’t know how to help him.

“I don’t know how to say this,” Griffiths says in a low voice. “But I did say to my wife: ‘I just hope Terry ain’t the next Aboriginal death in custody’, after the last time I seen him because he was so withdrawn … I just couldn’t get him to open up to me, you know, and I didn’t want to push it any further with him. He was just, he wanted to – ” he searches for the words. “I felt like he was keeping something to himself and that was hurting him.”

Griffiths lives in the tiny farming town in north-west NSW, more than six hours from the jail where his oldest boy spent the final hours of his life. He says he is angry about the way the department has treated him but doesn’t know what else to do.

“I’ve just held myself together, you know … [but] I do feel frustrated because I gotta just sit back and wait for someone to call me. I don’t know who to call or I try and call people and I just get no answers.”

One and a half years later, the NSW Coroners Court is yet to set the dates for the inquest into Terry’s death in custody.


Anger, frustration and helplessness are recurring themes for the families of prisoners who die in custody. Separated from their loved ones and powerless to intervene in their care, families are devastated as much by the culture of secrecy and misinformation that surrounds these deaths as by the deaths themselves.

“I don’t know a single family that has not experienced … the denial of information, the experience of misinformation and the smothering of truth,” says Charandev Singh, a human rights advocate and paralegal who has worked on deaths in custody for almost 20 years.

“Secrecy is systemic when it comes to the police and prison institutions, but it intensifies around deaths in custody,” he says. “Police and Corrective Services know a vast amount about what happens around a death in custody because they’re there … [But] from seconds after the death, it’s usually a process of trying to shield themselves from real scrutiny and real responsibility,” he says.

The problem has lingered for decades. In the final report of the Royal Commission into Aboriginal deaths in Custody, delivered in April 1991, Commissioner Elliott Johnston wrote: “[T]he anguish of relatives and their fears and suspicions have not been appreciated by persons involved in post-death investigations, and the family of the deceased have often been dealt with in a way which heightens their worst suspicions … In many instances, custodial authorities have been secretive and defensive about a death in custody, rather than recognising the fact that relatives and the public have a right to know what happened.”

A year earlier, in a paper delivered at the Institute of Criminology Seminar on Coronial Inquiries, Commissioner Wootten noted that police and prison officers often used pending coronial inquiries “as a shield behind which to hide”, and insisting, for example, that “nothing can be said until the coronial investigation is completed and the inquest over.”

Little has changed, it seems.  NSW police and the Department of Corrective Services refused to respond to Crikey’s questions about specific deaths in custody, saying that cases pending coronial investigation could not be discussed.

Ray Jackson, veteran deaths-in-custody campaigner and head of the Indigenous Social Justice Association, says the NSW prison system has become increasingly inscrutable. Jackson has spent more than 20 years working in the jail, police and court system, advocating for indigenous rights.

“It’s changed over the past three to four years. [When I was an official visitor to the jails] there was a set protocol [for Aboriginal deaths in custody]. The family was contacted by the jail. If they lived locally, there would even be a visit to the home to tell them. The family had the right to visit the cell, the death scene … They would get a pretty good run down verbally from the governor and the workers as to what happened and how it happened,” he says.

“The family would get a copy of the … notification of a death in custody to the coroner. They don’t get that any more. They would get copies of the two autopsy reports — the interim report and the final report. They don’t get that any more. On some occasions they were given access to jail files and stuff like that. But that’s stopped now as well,” he says.

“Families are now told nothing.”


The Drury family — like other families of prisoners who die in custody — endured an excruciating wait for the coronial inquiry into their sister’s death. For more than two years, Geoffrey Drury asked one question: why his little sister — a person whom seemingly everyone, including the prison health officers responsible for assessing her mental state in the days before her suicide, described as “happy” — hanged herself in a Sydney prison cell in March 2009?

The inquest into the death was held last month, yet Drury is still asking the same question.

Aboriginal transgender woman Veronnica Baxter was found dead in Silverwater’s Metropolitan Reception and Remand Centre — a maximum-security prison for men — six days after being arrested on charges of supplying illegal drugs. From all accounts, including that of police, Baxter had been coping well when she was transferred from police to prison custody on March 14, 2009. Even the corrections officer who interviewed Baxter when she was admitted to the jail told the inquest that Baxter had been “smiling, happy, talkative”.

Two days later, the 34-year-old committed suicide.

“It’s just unreal … She had her troubles but she seemed to handle it all right,” says Drury. “She’s been in custody before [in Queensland] and nothing like this has ever happened. It was just such a shock.”

In the days following the news of Baxter’s death in custody, Drury travelled from his home in Cunamulla, Queensland, to the jail in Sydney’s west to see for himself the cell where his sister had spent her last days. He wanted to speak to the people in charge that day.

Recalling his notes from that meeting, Drury said he was told that on the day of her death, Baxter was locked into her cell at about 3pm. Her body was found just after six the following morning. He was told that no cell checks were conducted during the night, despite reports from inmates that they heard “gasping” coming from one of the cells.

“Fourteen hours … and not even a wander around in the middle of the night — and that’s after people heard gasping. I mean, people rung up and said they could hear gasping and nobody bothered to … come down to see what it was,” Drury says.

“I just can’t believe — you know, that’s [the prison] where you first go to get processed and yet they don’t check on ’em during the night. I mean, you’re locked up there, you’re worrying about everything. That’s the time you’re gonna do something to yourself … That’s when you’re at your most vulnerable.”

However, at the inquest into the death — scheduled to run over two days last month but concluded in less than four hours — NSW Deputy Coroner Paul MacMahon found that no action on the part of police or Corrective Services had contributed to the death. There was no discussion of any “gasping” heard on the night of her death, although the inquest did reveal that Baxter had repeatedly used the emergency “knock-up” button in her cell to call prison staff.  No one at the prison could recall who had answered her calls or what she had wanted, however.

Then there are the other questions aired at inquest but not satisfactorily answered, according to some. “The fundamental issue of why Veronnica was in a male prison has not, to my mind, been adequately addressed — and we will certainly be looking further into this … It seems remarkable that a transgendered Aboriginal woman who openly identified as a woman was housed in a male prison,” NSW Greens MP David Shoebridge wrote in an email statement to Crikey.

“The Greens will be calling for a Parliamentary Inquiry into the circumstances of Veronica’s death,” he wrote, adding that the Greens had “significant concerns about the adequacy of the coronial inquiry”.


The Victorian Law Reform Committee’s 2006 inquiry into the Coroners Act 1985 highlighted the difficulties faced by families at inquest. According to the committee’s final report, one of the most significant issues was the disparity in legal representation between families, on the one hand, and government or private institutions, on the other, at inquests: “This is of significant consequence in those instances where the conduct of a well-funded organisation is at issue: for example, in the case of deaths occurring in the care of a health organisation or in custody.”

Recommendation 23 of the Royal Commission states: “That the family of the deceased be entitled to legal representation at the inquest and that government pay the reasonable costs of such representation through legal aid schemes or otherwise.” Singh, who has worked in five Australian jurisdictions but is based in Victoria, says about half of families involved in inquests into deaths in Victorian prison custody do not have any legal representation at inquest. Even when families are represented, the power imbalance is striking: “You walk into an inquest and the disparity of power between families and the government departments and corporations is enormous … We are outspent 20 times to one.”

What is also apparent at inquest, Singh says, are the priorities of a system that throws almost unlimited resources into legal costs following a death in custody, yet spends a fraction of that on support services that would tackle the causes of crime and help to reduce these deaths.

“All of a sudden when their daughter dies or their son dies, there are all these resources for lawyers and inquiries. But when they were crying out for help, when … [they] needed emergency housing or needed a refuge … when they were threatened with domestic violence, there was nothing. That’s really hard for families to stomach,” he says.

Beyond the financial concerns, families must carry the burden of grief, trauma and other emotional issues such as fear of the courts and mistrust of institutions.

“[When] a loved one who has been taken away by authorities and put into the authority’s custody then comes out dead, it’s a shocking trauma to family — and an even greater trauma to Aboriginal families because it all fits within the dreadful historical record of authorities dealing with Aboriginal people over 220-odd years,” John McKenzie, chief legal officer for the NSW Aboriginal Legal Service, says.

“What we actually find is the greatest trauma to these families is if another death happens in similar circumstances; when no one has done anything to put into effect the recommendations that the initial family thought that they had fought so hard for,” he says. As Crikey’s special investigation into deaths in custody has revealed, there are many recommendations yet to be implemented and lessons to be learnt.

Two years and two months after his sister’s death, Drury is still waiting for someone, somewhere to do something.

“See, I don’t know,” he says. “I’m not up there on what you’re entitled to. I’m just a poor, simple old station hand.”

Poor though he may be — particularly when faced with the might of the police and prison institutions — Drury recognises an injustice when he sees one.

“They did a big inquiry into this and this was not supposed to happen again — and yet it’s still happening,” he says.

“That’s why they like these bloody coroner’s inquiries, because they take so long. I think they just wait and they drag it out as long as they can so either people get frustrated with it and give up, or the memory gets foggy and facts just get lost.”

But Drury is not about to give up nor is his memory fading. In fact there are still times, he says, when he catches himself expecting to see his kid sister walk through the door.

“There’s days when, you know — especially family functions. You don’t realise how much you miss someone until you have a family reunion, a birthday party and she always called, sort of thing … come back up for Christmas, sent flowers to mum for Mother’s Day, always,” he says.

“It’s when you have your family functions and birthday parties that people who don’t know ask: ‘How’s the family going? How’s Veronnica going?’ and they don’t realise … Just brings it all back.”

*This is the sixth in a series of case studies and investigative reports into prison deaths. Next week, how families are let down by a negligent system.


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Peter Fray
Peter Fray
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