Demographics
unknown
Date of death
1998
Finding date
1999-11-24
Cause of death
Four deaths: three by self-inflicted hanging, one by multiple injuries from fall
AI-generated summary
Four Aboriginal Tiwi Islanders died in 1998 from suicide by hanging (three cases) and by falling from a power pole (one case). The inquest identified widespread alcohol and cannabis abuse, domestic violence, cultural dislocation, and lack of employment opportunities as underlying contributors. Three of the four deaths had significant blood alcohol levels (197, 146, and 199 mg/100ml). The coroner found no medical errors or clinical negligence; deaths resulted from complex social, cultural, and substance abuse factors affecting a remote Aboriginal community. Key preventive measures recommended include alcohol restriction through licensing reform, stronger policing presence, domestic violence services, youth programs, school-based interventions, and coordinated government responses to address root causes of despair.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Drugs involved
Nos. 9817541, 9817544, 9823271, 9825948
Inquest into the deaths of
The deaths of the above-named four persons occurred during 1998 on the Tiwi Islands of the Northern Territory of Australia. The deaths are
“reportable deaths” within the definition of that term in 3.12 of the Coroner's Act (“the Act”) in that they appeared
“to have been unexpecied, unnatural, or violent or to have resulted directly or indirectly, (rom an accident or injury”.
This Inquest is held as a matter of discretion pursuant 16 5.15(2) of the Act, and 8.14(4} allows more ‘than one death to be the subject of any particular
Inquest. Sections 34 and 35 of the Act set out the limils of my jurisdiction as follows:
A coroner investigating -
(a)
a death shall, if possible, find —
(i) the identily of the deceased person; (ii) the time and place of death’ (iii) the cause of death:
(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act;
(v) any relevant circumstances concerming the death; or
(b) a disaster, - - - - -
(2) A coroner may comment ona Mmatier, including public health or safety of the administration of justice, connected with the death or disaster being invesligated.
(3) Accoroner shall noi, in an investigation, includc in a finding or comment, a statement that a person is or may be guilty of an offence. -
(#4) A coroner shali ensure that the particulars referred to in subsection (1}(a)(iv) are provided to the Repistrar, within the meaning of the Births, Death and Marriages Registration Act.
(1) Acoroner may report to the Attorney-General on a death or disaster investigaled by the coroner.
(2) Acoroner may make recommendations to the AtiorneyGeneral on a matter, including public Health or safety or the administration of justice connected with a death or disaster investigated by the coroner.
(3) A coroner shall report to the Commissioner of Police and the Director of Public Prosecutions appointed under the Director of Public Prosecutions Act if the coroner believes that a crime may have been committed in connection with a death or disaster investigated by the coroner.”
Islund, Tiwi Islands, Northern Territory. In attendance at the Council
offices were Aburiginal interprelers, [amily members, council members, elders and members of the Tiwi Health Board. Counsel assisting me was Mr Colin McDonald Q.C. instructed by Ms Emma Sommerville. The families of the deceased appeared and were represented by Mr Michael Jones. Mr David Farghauer sought and was granted leave to appear on behalf of the Northern Territory. Mr Priestly sought and was granted leave to appear on
behalf of the ‘Fiwi Health Board.
T suppress the publication of the names of the four deceased persons.
First-mentioned deceased:
(1) The identity of the deceased was Gary Peter Tipungwuti, a male | Aboriginal Australian born on 27? February 1980 at Darwin in the
Northern Territory.
(2) The time and place of death was at Nguin community township at Baihurst Island in the Northern Territory at some time prior ta
discovery at approximately 2.30 am on 21" August 1998,
(3} The cause of death was self-inflicted hanging. There is no evidence
to suggest suspicious circumstances or fonl piay.
(4) The particulars required to register death are:
(i) The deceased was a male.
(ii} The deceased was of Aboriginal Australian origin.
(iii) The death was reported to the Coroner.
(iv) The cause of death was confirmed by pust-morlem
examination.
{v} Sclf-infficled hanging caused the death.
Sccond-mentioned deceased:
(2)
(4)
(vi} The pathologist viewed the body after death.
(vii) The pathologist was Dr Terence John Sinton of Royal Darwin
HAaspital.
(viii) ‘Phe father of the deceased was Michacl Tipungwuti and his
mother was Marina Tipungwuti.
{ix} The usual addzcss of the deceased was Forestry Camp, Nguiu
Community, Bathurst Island, Northern Territory.
(x) The deceased was unemployed.
The identity of the deceased was Patrick Raymond Kerinaiua, a male
Aboriginal Australian born on 19" August 1973 at Nguiu, Bathurst
Island in the Northern Territory.
The time and piace of death was at Nguiu community township at Bathurst Island in the Northern Territory at some time prior to
discovery at approximately 12.10 am on 22! August 1998.
The cause of death was self-inflicted hanging. There is no evidence
ta suggest suspicious circumstances or foul play, The particulars required to register death are: ~ (1) The deceased was a malc.
(ii} The deceased was of Aboriginal Australian origin,
Gii) The death was reported to the Coroner.
(iv) The cause of death was confirmed by post-mortem
cxamination.
Caan
(v) Self-inflicted hanging caused the death.
(vi) The pathologist viewed the body after death.
(vil) The pathologist was Dr Terence Johu Sinton of Royal Darwin
Hospital.
(viii) The father of the deceased was Raymond Kerinaiua and his
mother was Elsa Kerinaiua.
(ix) The usual address of the deceased was Forestry Camp, Nguiu
Community, Bathurst [sland, Northern Territory.
(x) The deceased was unemployed.
Third-mentioned deceased:
(1)
. @)
(4)
The identity of the deceased was Noclenc Puantulura, a female Aboriginal Australian born on 2"" March 1976 at Nguiu, Bathurst Island in the Northern Territory,
The time and place of death was at Nguiu community township at Bathurst [sland in the Northern Territory al same time prior to
discovery at approximately 8.30 pm on 28" Octaber 1998.
The cause of death was. multiple injury suffered as the result of a fall.
There is no evidence to Suggest suspicious circumstances or foul play
and T record a finding of death by misadventure.
The particulars required to register death are:
{i) The deceased was a female,
(ii) The deceased was of Aburipinal Australian origin.
(iii) The death was reported to the Coroner.
oe
(iv) The cause of death was confirmed by post-mortem
examination.
(¥) Moitiple injuries suffered as a result of a fall caused the death.
(vi) The pathologist viewed ihe body after death,
(vii) The pathologist was Dr Terence John Siaton of Royal Darwin
Hospital,
(viii) The father of the deceased was Noel Puantulura and her mother
was Franciose Puantulura.
{ix} The usual address of the deceased was Forestry Camp, Nguiu
Community, Bathurst Island, Northern Territory.
(x) The deceased was a housewife.
Fourth-mentioned deceused:
(1)
a
(2)
(3)
(4)
The identity of the deceased was Iohn Gerard Orsto, a male Aboriginal! Australian born on 4'" February 1966 at Neuiu, Bathurst
Island in the Northern Territory.
The time and place of death was at Nguiu community township at Bathurst Isiand in the Northern Territozy at some time prior to
discovery at approximately 11.30 pm on 30°" November 1998
The cause of death was self-inflicted hanging, There is no evidence
to suggest suspicious circumstances or foul play.
Tae particulars required to regisier death are:
(i) The deceased was a male.
(it) The deceased was of Aboriginal Australian origin.
| Gili) ~The death was reported to the Coroner.
(iv) The cause of death was confirmed by posi-mertem
examination.
(v) Self-inflicted hanging caused the death.
{vi} The pathologist viewed the body after death.
(vii) The pathologist was Dr Terence John Sinton of Royal Darwin
Ilospital.
(viii) The father of the deceased was Jules Orsto and his mother was
Annette Orsto.
(ix) The usual address of the deceased was Forestry Camp, Nguia
Community, Bathurst [sland, Northern Territory.
(x) ‘The deceased was a part-time employee of the Nguiu Social
Club.
The Aboriginal community on the Tiwi Islands of the Northern Territory numbers about 2,350 persons. The community is composed of one discrete full-blood Aboriginal population. The community is pcographically scparated from the Australian mainland, ‘here are two main islands, Bathurst [sland and Melville Island. The biggest township is Nguia, which is situated on Bathurst Island,
This township has a population of approximately 1,500 persons (out of the 2,350 whe live on the islands). This community has a rich and complex cultural
herilage, which the evidence at this Inquest shows is still cxisting to this day.
In my view, as a visitor to the community on several occasions over several years and having regard to the evidence called at the Inquest, the community functions well in lerms of governance. The Aboriginal witnesses called during the Inquest, including groups of youths questioned in gtoup sessions, all showed themselves tu be perceptive and proud. ‘Phere is relatively little serious crime. The population is stable, relatively well-educated compared lo ciher remote Aboriginal communities and with more than the occasional person who has been educated to post-primary level at southern boarding schools. There are a number of economic initiatives on the Islands which should provide jobs and income.
This description of the community is in contra-distinction to some other remote Aboriginal communities in the top end of Australia, which I visit from time io time in my capacity asa Stipendiary Magistrate. There are some other Aboriginal communities which are almost dysfunctional in terms of governance and social cohesion. The people of these communities ure poorly educated, in every sense of the word, and many persons are insecure with pride diminished.
In these communitics serious crime is rife, however, suicide and self-harm
problems are not as high as on the Tiwi Islands,
The Tiwi Islands have a problem that these other less well ordered communities da nat have. The ‘Tiwi Islanders are suiciding and/or attempting setf-harm at an alarming rate. The senior Northern Territory Police Officer un the Islands (Sergeant Peter Cumming} gave evidence that in the past 12 months he has been called cut to over 50 suicide attcmpils; furthermore, the powet station at Neguiu has had to be shut down on over 40 occasions since the beginning of this year to stop harm to individuals who had climbed power poles ihreatening to suicide. This year there have been twa apparent suicide deaths, ‘The Tiwi Islanders have had the courage (o assist me in evety way they could with this Inquest into the deaths of four of theit people during 1998, apparently from suicide. These are the only four such deaths during 1998. Accordingly, a stated focus of this Inquest was on the emotional and mental health of the Aboriginal people of the Tiwi Islands (28 opposed to the physical health needs). In passing, however, it is to be noted that these physical health
needs are apparently well met and resourced by the Tiwi Health Board (and Territory Health
Services}.
The youth of ihe island, with whom [ spoke with in group session during the Inquest, impressed with their intelligence, enthusiasm, sense of humour and potential. It is to be noted that the Elders specifically invited me to do so, and not in their presence. They were possessed of ambition and career aspirations. A lot of them are enthusiastic about education and want to go on to find jobs. They talked about sport both on the islands and “down south”. They watch the same television programs that a loc of urban city dwellers watch and I am sure have a lot of the same dreams as any other group of young people around Australia.
What is their future in terms of carcer aspirations and dreams on the islands? I very much suspect that for the same reasons that suicide rates amongst young people are higher in rural areas of Australia so is the case on the Tiwi Islands.
That is to say, in my view, problems such as unfulfilled potential, frustrated ambition, boredom, unemployment and non-achievement in terms of carcer aspirations all play a part in the suicide and self-harm statistics. This problem is more evident on the Tiwi Islands than same other less functional Aboriginal communities in similarly remote locations precisely because many Tiwi Islanders are relatively better educated and exposed to Western ideals which are not
currently achievable on the islands.
Mr McDonald Q.C. and Mr David Farquhar have assisted this Inquest greatly with written submissions which I annex hereto. I must thank the Minister for Territory Health Services for funding Mr Farquhar’s attendance. I shall not repeat a lot of what they say, but lagree with them and their submissions should be read as part of these findings. The Inguest was conducted in a completely noo-adversarial manner and the thoughts of these two expericaced counsel mesh well together and mirror most of my thinking as well as the evidence. | specifically adopl and [ind as a resull of the evidence, Lhuse malters pertaining to cach of the deceased as set out in paragraphs 10 through to 14 in the submissions
of Mr McDonald Q.C.
It is to be noted that three of the deceased had significant alcohol readings at the time of their deaths, viz. “Second deceased”, 197 mg/100 ml, “Third deceased”, 146 mg/100 ml, “Fourth deceased”, 199 mg/100 ml. All of the deaths occurred al Nguiu and the deceased were al! Nguiu residents. Nguiu has a social club, which is licensed to sell alcoholic beverages. The liguor licence allows only draft keg beer to be sold with sales being restricted to between 4 pin and 7 pm every day of
the week except Sunday, There are three other licensed clubs on the islands,
The evidence established that there were about 1,500 people resident in Nguiu (men, women and children}. The evidence established thai the majority of aduli Aboriginal men congregate at the club every afternoon and drink. In the financial year 1998/99, Liquor Commission records reveal (and therc is no reasan io doubt their accuracy) that 206,168 litres of full-strength beer was sold at the club, as well as 10,391 litres af low-strength beer. I note that licensing restrictions prevent the sale of this alcohol te juveniles under the age of 18 years (alihough there was some evidence that this restriction is and has been circumvented from time to time). I also note that the evidence leads to a reasonable inference that mast of this beer is drunk by adult men rather than adult women. The records show that during this particular financial year a total of 417,810 litres of full-strength beer were suld on the islands. I also note that ihe. evidence reveals that people who are not resident on the islands necd permits from the Land Council to entet and retain on the islands. It is a reasonable inference on the evidence to conclude that atmost all of the beet is consumed by the local population. The Liquor Commission records indicate that approximately $1 million worth of beer (in wholesale terms) was purchased by the clubs on the island during the 1998/99 financial year, [ also note that the evidence Suggests that many of the population are young and under 1§ years of age. There is no doubt, as the evidence reveals that the abuse of alcohol is one of the major underlying factors ia relation to suicide and self-harm. Ja my vicw,
the abuse of alcohol is net so much one of the symptoms of the causes underlying
io
the suicide rate but rather one of the causes itself. I shall return to this subject a
little later in these findings.
In my view, the starting point for identifying strategies for the prevention of suicide and self-harm on the Tiwi Islands is to realise the great siresses upon the population. [t may be obvious, however, it ought be said that their traditional cullure and beliefs exist uneasily in today’s modern warld. Western ideas af individual achievement, competitiveness, work ethics, definitions of success, ownership Tights, and just what is important in Hile are acquired and learaed by the Islanders. These concepts are reinforced by daily access on the istands lo all the ordinary communicalion [acilitics of modem cilies, eg. satellile dishes, video movies, “five-channel” television, radio, telephone, facsimile machines, newspapers etc. Al the same time the people are proud uf Lheir Aboriginality, history and culture. The elders, and their authority are generally respected, concepts of cammunity/kinship/extended family/sharing are very much part of
everyday living.
Many of the youths that I spoke to identified what might be called “relationship” problems within familics as one of the motivations for sclf-harm. Many of these
“relationship” problems were to do with alcohol abuse and cannabis abuse.
Alcohol abuse leading to domestic disharmony and marijuana abuse leading to the same thing (caused by more and more money being spent on it), An example of the uneasy juxtaposition between Western ideas and Aboriginal culture on the island was given of some of those with paid jobs being expecied (and il usually being donc} to share and give away their pay packet to family and relatives, and friends. Also parents were asked by their children for money (and usually expected to simply give). Adults were simply not in the business of saying “ The idea of working hard and keeping one’s remuneration for oneself as a reward for such hard work, was forcign to Aboriginal ideas of community ownership and sharing. In the WesLern world one is expected to work hard and is rewarded by a pay cheque and yet in the Aboriginal world it is expected that the rewards be
handed over to be shared amongst the extended family {a lot of whom do nat
work at all). The word “confusion” was used more than once in identifying the problems in this regard. !t is little wonder that the Aboriginal Community Police Officers (ACPO’s) who are part of the exiended family on the islands do little to enforce, as the evidence suggests, the law in relation ta consumption of cannabis and domestic violence. Yet they are the only permanent police presence on
Bathurst Island.
A very wise judge once said in relation to Aboriginal youth in the Northern
Tertitory:-
“..in dealing with Aboriginal children one must not overlook the tremendous social problems they face. They are growing up in an envitonment of confusion, They see many of their people beset with the problems of alcohol, they sense conflict and dilenima when they find the strict but community-based cuitural traditions of their people, their customs and philosophies set in competition with the more tempting
short-term inducements of our society.
{a short the young Aboriginal is a child wha requires tremendous care and
attention, much thought, much consideration.” (Jabuitjaril y Hammerstey (1977) 15 ALR 94 (NT) Muirhead J (at 98),}
Thbse words are just as apt in 1999 in describing youth on the Tiwi Islands as
they were in 1977 in desctibing the youth in and around Alice Springs. me
In December of last year | handed down corenial findings in reiation to the death in Alice Springs of a 16-ycar old Aboriginal youih who died in the police Watchhouse as a result of self-inflicted hanging (Ross). The deceased had a
blood aleohol reading of .062%. 1 was compelled, amongst other things, ta say
(page 38):-
“Underlying, the death of this juvenilc are the great social problems in Alice Springs eaused by alcohol and cultural stress, The sad aniecedents and history of the deceased
juvenile are not unusual. These problems cannot be underestimated and are evidenced
yast majority are Aboriginal.”
Unfortunately, these problems are not just to be found in and around Alice Springs and, as the evidence disclosed in this Inquest, they are to the fore on the Tivai Islands, Such problems have been identified in past years to some extent and | refer to the Inquest into the death of Kantilla who dicd on 1 May 1996 aficr being arrested by an “ACPO” at Nguiu.
The deceased died by his own hand, by banging himself. 1 quote from the findings as follows (page 10):-
“The deceased was a 42-year old Tiwi man who was married to Amy Gaden. There . Was an unfortunate background of alcohol abuse and domestic violence in the Telationship. At the time of his death the deceased and his wife were living ‘at Nguiu.
On the day of his death, Amy Gaden had spoken to Senior Constable Taylor at . Neuiu, withdrawing charges of assault upon her against her husband. The deceased*s
wife had also withdrawn Teslaiping proceedings.
The evidence shows (hal the deceased and his wife attended the Neuiu Social Club on t* May 1996 between about 4 pm and § pm. The deceased consume! a substantial amount of beer. In one of her statements (Exhibit 15) Amy Gaden described her husband as “being full drunk”. It should be noted that the deceased’s
post mortem blood/ulcohal reading was 228 mg per 100 ml (see Exhibit 5}.”
Those particular published findings also included comments about the need for a permanent police presence on Bathurst Island. That is to say, the need for a permanent police station Gneluding residences) staffed by fully trained Police Officcrs {and not just ACPO's). [ quote page 19 of these findings as follows:
“During the month of October 1995 correspondence passed benveen the President of
the Newiu Community Government Council and the Chicf Minister.
ioe
On 11" October 1995 the Council President, larry Puruntatameri, wrote to the Chict Minister indicating that the community fully supported a 5-year development plan for a construction of a new police station, cells and residences to be included in the forward Police Capital Works Projects for 1996/97 and stated:-
“Council over the last 10 years has frequently requested the upgrading of police operations at Nguiu but to date no action has been taken by Government, Most requests ate met by the statement ‘that the community elected some 20 years ago to not have a permanent police presence at Nguiu’
however, the situation at Neuiu has changed dramatically since those days.”
Ou 27" October 1995 the Chief Minister wrote to the President of the Neuin
Community Government Council and said inter alia:- “I am aware that a number of previous requests from Neuiu fer the construction of a permanent police slation on the community have been unsuccessful due to insufficient justification upon an analysis of needs, priorities and resources.
These considerations are, however subject to ongoing monitoring by the
Northern 'lerritory Police”.
F also uote that the Town Clerk of Nguiu at the time pave evidence in that Inquest and was
quoted al page 29 of the published findings as follows:
“The Town Clerk of Nguiu gave important background and evidence in his private SC capacity of the inler-relationship of alcchol abuse and persons being placed in . lockups. He termed the inter-relationship and the context of alcohol abuse as a “social arder issue thal can at times lead to police action and is an issue that needs to . be addressed by the community as a whole ...” (sec exhibil 32). Mr Harris assessed that about 90% or more of the problems in any Aboriginal community are aicohol related and that wider necds and issues need (o be considered than simply the
provision of ceils.”
Finally, [note that the Coroner’s recommendations in relation to that 1996 Inquest included
specifically the following (at page 44):-
“(3) Phat the NT Liquor Commission Inspectors visit the Tiwi Islands when Tequested to by police or Neuiu Council io assist police in enforcing the Liquor Aci
and its Regulations in relation to ail licensed premises,
(4d) = That al) Tiwi [sland licensed premises consider the closure of each club for the period known as “Bush Holiday”, for the purposes of continuation of
traditional ceremonial customs and cultural preservation.”
The community has recognised that it can no longer be reactive to suicide/self-harm but rather il must be pro-active. Ms Denise Luta (an Aboriginal Tiwi [slander working as a
' counsellor) gave evidence of this (at page 38)
“And the councils were just starting to pull together as — and the clinics and the councils aud the sport aud rec and ihe schouls. You know, it’s all positive encrgy
there, we're trying to da things.” .
In this regard, measures such as the “Tiwi for life” programs have been instituted over the past year with some success. The magnificent work of Ms Luta (counsellor employed in this program) has to be recognised. Also the stresses involved must also be recognised and,
T note that a counsellor apparently suicided in the last few weeks on the Islands.
The word “confusion” was used several times by Aboriginal witnesses to describe the state of mind of young people. The (then) President of the local community council Mr Danny Munkara said in reference to underlying, problems (page 22), “Things been changing year after year wilh generations. Like video, new things happen, They’re looking towards western culture now”.. A council member, Mr Maralampui said (page 23) “....it’s confuse
everyone. Because of the lifestyle — modern lifestyle taday.”
Mz Danny Munkara was blunt in saying to me that he thought one of the main problems (in the context of suiciding and self-harm) was marijuana and alcohol (page 23), “it doesn’t fit in well, you know. This is creating the problem.” Mr Munkara believed that the creation of mnore activities, more jobs, more sport is a partial answer to the unhappiness leading to snicide/self-harm. Mr Danny Munkara gave evidence that the smoking of marijuana at
Nguiu was endemic. The majority of youths smoke it, “even the 14 and 12 year olds”. Mr
w
Barty Puruntatameri (the newly elected president of the Council) told me explicitly that the
problem was “loo much grog and too much ganga coming into this community”.
Barry Puruntatameri gave further evidence on 10 November 1999 and said (page 229):
“Would you like to see white policemen at Neuiu?---I like, [like to see tro policemen, Huropean policemen jusi based at Nguin. That problem won’t be never ending till we have — that problem of the suicide and grog problem will be never
ending till we have éyo Evropean policemen based full-time at Neguiu.
Has that always been the thoughts of the council at Neuiu?-—Yes.” And (page 230):
“MR FARQUIIAR: Mr Purnntatameri, to make it clear, you want all of the four clubs to shut over the bush holiday?---Yes.
You want none of the four clubs to be able to scll takeaway beer?---Yes.
You want the clubs only opened on Monday, Wednesday, Friday and Saturday?-—- Yes.
And you want twa European police officers based at Nguiu?.--Nauiu.
So that the coroner knows and the povernment knows, 1 know you're Mr Puruntatameri and you’re with the health board, but you are asking a lot — who else ee wants this? Who do you represent — is it just your or can the coroner say, there is a
strong - - -“ A few days later he was clecied president of the Council. He is a recognised Elder.
Some of the women spoke up at the Inquest and identified the following problems, Ms Ulamura said (page 27):
“Husband go to the club and when they go home, they abuse their wives and
sometimes hit their children. And they come to me and I send them to Darwin,
whore the shelter. So we need to build up that shelter at Norforce so L can keep all
our women and children safety.” And Ms Luta (page 27):
“Like, a lot of problems here, we have no safe house for women, right now. A lot of the problems we haven’t even started — we haven’t got funding, we haven't got a
The women told me that domestic violence occurred “nearly every day”. Mr Munkara
didn’t disagree and ihe fullowing was said at the Inquest (page 28):
“Speaking of relationship, didn’t happen in the past. We had strong relationship with the family in those days. Today relationship with dra g and alcohol, not the family.
A vety perceptive and strong-minded Aboriginal lady (Esther Babui) at the Inquest (a
member of the local communily council) said to me (page 29):
“Whea you talk about a relatiouship broken up, I think it’s individual people and sometime —I sec that-born and breed here, a tot of young Tiwis depend on drinking and takes too many dmg. And some of them drown their sorrow in it. It’s explodes out of proportion after they take drugs, twa things at the same time. That’s when
domestic violence comes in.”
Ms Babui also said about the youth, “If we don’t give them money for marijuana, they say they’li hang themselves”. ‘This idea of suicide/self-harm being used as a blackmail device.
for moncy and attention was cvident throughout the Inquest.
Early in the Inquest one of the Eiders identified as a strategy in helping to relieve the problem, the need to work with the school, with the kids, including getting the kids to attend school. Apparently non-attendance was becoriing a teal problem. (Mr Maralampui, page 45}.
One of the two Northern Territory police officers stationed on the Islands (ou Melville Island at the small community of Pitlanjimpi (Pularumpi)), Constable Moore, gave evidence that spoke of the beneficial effect of the “Tiwi for life” programs run by the Tiwi Health Board. He also identified as a factor in the suicide probiem, the big funerais held for victims which revered the deceased. These funerals extend aver several days with ail of the good qualities of the deceased being recognised and applanded. There was no: particular shame involved in the manner of death as in Western sociely, Constable Moore believed
this encouraged “copy cat” behaviour. Sergeani. Cumming was of the same vicw.
Constable Moore gave evidence on the marijuana problem (page 57):
“Now yesterday we heard frum a number of witnesses that they saw a problem with the smoking of ganga, particularly the smoking of matijuana with alcohol. Do you accept there is a problem with the smoking of marijuana in this community ?--- Yes, I do. T accept there’s prehably a large problem on Melville Island and Bathurst Island, the whole actually of the Tiwi Island.
And in you experience — your direct police experience —do young people smoke
marijuana?--- Yes, definitely.
And how young is the youngest person you've come across in your police work who
smoke manjuana?---P'd say 10 years old.
Now, are you — do you have any information that would suggest how big the problem
with smoking marijuana is?---No, I wouldn’t have any information as far as stats wise, just only from experience. Although I do find that in every community that I
have served at or been related to, it is a problem. And I haye to say because of the
_ Size of this particular community it is a — comes out to be a bigger problem.
Are yuu talking about Bathurst Island or Nguiu itself? ...Nguiu itself.”
Constable Moore spoke of ihe changes at Nguiu since he first started to go there; crime has increased ~ “break-ins and stuff like that”, children running around the sireets at night. The
Constable believed the answer to these problems was {page 58):
“The number one being as a deterrent immediately would be extra policing which we've spoken to with our department numerous times on behalf of the council and on behalf of the Tiwi people. Due to funds and other reasons basically that will not be
occurring immediately”.
and, in reference to Newiu/Bathurst Island (page 72) -—
here all the time.
We have effectively three very large communities to run, not just this one and it’s “very difficult because normally with a population size of 2,000 like this, they should ” have at least some police. That’s my opinion, anyway — should have some police
_ seven constables based there.”
Constable Moore spoke of the beneficial effects of the annual “hush holiday” where all families and kids would go from their communities into bush camp and focus on traditional ’ values, culture and living (for approximately five weeks of the June schoo! holidays).
Unfortunately, because the licensed clubs are now staying open during the period, the annual bush holiday has rapidly declined in valuc and use. Many men stay put in their communities so as to access the “club” for grog. The Constable and many other wimesses
wanted the clubs to be closed for the bush holiday.
Constable Moore also noted with deprecation the absence of school based constables
(something schools in other parts of the Northern Territory have), (page 66):
THE CORONER: “I mean, is it right — do you think there’s any substance to say this; that the physical health of the people here is relatively okay and resourced and the population’s increasing all the time. Maybe what’s been left behind is life skills,
counselling, education and the — what we were talking about yesterday, the mental,
emotional and spiritual health hasn’t kept up with that increase in population and the
efforl put into physical health.
MR MOORE: I'd agree with that totally, sir. One of the other issues that T find astounding is that they don’t have a school-based constable. Just from the population, they had to ga through the school, they had actually two schools here and basically some of the smaller communities actually have a schoo!-based constable
which lias not even half the size of the population.
And I think by having a schoul-bused constable here, you'd probably find that they could educate and run a lot mere programs through the school with the children.
THE CORONER: So we’ve got a school here about ihe same size in terms of population as, say, schools in suburban Darwin and they've got school-based
constables.
MR MOORE; That’s correct, We have a boys’ school, as you're probably aware of and a yizls* school next door, I don’t know what the actual pepulation of children, but it would have to be at Icast half to three-quarters of the community — of
this community that allends the school und it’s a fairly regular thing.
MS LUTA: I think there’s about 400 actually.
MR MOORE: I mean 400 and the primary schools in Darwin, I mean and —
The resident medical practitioner at Nguiu (employed by the Tiwi Health Board), Dr Chris
Hartison, gave evidence of the health problems encountered by him since 1996:
“Now when you arrived in 1996 what were the main health problems that you identified as the resident medical officer on the island?---l first went to work in August 1996. You could probably group the health problems into infectious type of health problems, pneumonias, gaslroenteritis, skin scores, scabies, those sorts of
problems which are provide, I guess, the main burden of work of the island. The
oon,
second group were the newer chronic diseases such as the renal disease, hypertension, diabetes, those sort of lifestyle issues. They were the second major group of diseases. And thea F guess the mental health problems is another yraup that
T guess we were dealing with to a large extent as well.” (page 79).
“Yes, thank yau. Now in terms of the current, the main health problems, are you able
to say what they are?---Again, yeah, 1 mean the bulk of our work [ guess is divided
_ into those three main areas, infectious disease which is much less. The chronic
diseases program which provides —[ mean, is for us a large amount of work, We
“have a large screening and treatment program with the health workers and the health
ceatres. The third - certainly mental bealth issues have risea tu maybe an equal point in standing with those diseases. I think the community certainly view that
4S a yuu koow, as a third priority oow. There’s been a marked rise in the last
_ three years in mental health incidents and problems, .
When you say ‘mental health problems’ what sori of mental health problems do you
reer to?---Well, as ve —in thal document there which I’ve been just collecting the
incidences, self-harm events, suicide events, or threats of suicide ranging through te a form, I guess, of psychosis and also touching on alechol and cannabis usc,
precipitating sort of other crises or you know incidents within families.” (page 80)
“All right. Now in relation to the patterns that you discerned from your statistics and your staff’s contact with patients, does alcohol and marijuana abuse play a significant part ig triggering suicide event and attempted suicides? -Yes, I think it certainly does.
And do you say that marijuana — there is a connection between marijuana abuse
aud suicide?---Yes, I think there definitely is.” {pape 84)
Now the other paticrns of bchaviour that you saw emerge from the slatistics and your contact with patients and these reports of suicide and attempted suicide, what arc those patterns, doctor?---Something in terms of the age groups. There was a large
group of young males that were involved. An older group of — a small older group of
males and emerging more now is a group of young females attempting suicide. The — I suppose the other apparent factors are things such as family stress, relationship problems, conflict and arguments, they ure often a common precipitating facior.”
{page &4/85}
“ln terms of reporis of patients coming to see you about health problems or attempts of suicide are you able to draw a contrast between the period when the club was opening during bush holiday and when it was closed?---Certainly when the club was closed there was a much lower incidence of health problems and mental health problems generally. I mean, the clinic consultations probably decreased by about 50% in the year that there were no — that the clubs were shut. Even with bush holiday the number of consultations were reduced by about 25%. But certainly the two ycars it’s been opened recently — (hese last two years there has still
bee a lot of mental health problems while the club’s been open,” (page 88)
“And the titsi une you identify is a community drug strategy. Could yau please tell the Coroner what positive outcomes you would see from a community dmg Strategy?---I use that term community for that very reason. The community's got to actually, you know, run with the options and take it on and own it. Reduction in alcohol consumption, management of alcchol problems local ly, counselling available. Certainly have the club closed on the bush holiday gives people a break from alcohol and it would have tu be in all four communities, I guess the general sort of support for aicohal reduction or people wha want to dry out or who have got sort
. of mental health problems assuciated with alcohol. But the critical thing is the conmmunity or the health board or the land council, whoever’s got to own the strategy and support. The same with cannabis, marijuana, it’s an extremely difficult problem
in that if the people who are selling it or are heavy smokers are family members then to go to the police or to fave hat sori of role is, yau know if they’re a family member to dob them in is very difficult. Bui certainly the community came up with solutions and then support thern at 2 higher level in terms of the elders, you know healih board, land councils. Whether that be by policing or a massive education program
whith I sort of believe in.
Sorry, you believe in a massive education program. Can you be more specific about that please?---I think certainly cannabis is accepted as a day to day sort of thing and the young people smoking without any real knowledge of the harmful effects and you know ---“ (page 90}.
Taccept Dr Harrison’s cvidence and find it relevant and compelling. Tt comes from a Health
professional working at “the coal face” and encountering problems on a daily basis.
It must be said that all of the witnesses who told me about the suicide and sclf-harm —
problems (ie. Health workers and police) expressed a view thal the problem was widely
under-reported,
Senior Constable Chris Kilian (who had worked on the Eslands for some 244 years) said (page 1053/4):
“Are you able io, in relation to attempted suicide, give the Coroner any ° » Observations or views that you might have as a result of your experience over ~ those two and a half years serving on Bathurst and Melville Island?---It’s certainly an overwhelming problem. When I first arrived in the Tiwi Islands 1 was made aware of it by Sergcant Taylor whe was currently serving there, to the extent where basically every person you dealt with in custody really should be treated as an ‘at risk’ person. It was very prevalent thronghout the society and not just in one of
the communities but in all four major communitics,
When you say all four major communities, what are they?---Ranku community, Nguiu community on Bathurst Island and on Melville Iskand, Mitikapti and Pirlangimpi.”
and at page 105 (in relation to suicide and self-harm) he said:
“T think it quite often more than not - in fact probably most of the time involved
consumption of alcohol and drugs, cannabis.”
“How extensive was that abuse when you were there?=--(Qh, I'd say very
extensive, probably more so than any community that I’ve ever been to.
nF
Probably more so than Darwin. To the point it formed part of the lifestyle of most — Most peaple through a broad speettum. Not bound by just the youth but — because I suppose Tiwi Island has been using marijuana for so long you had people into their
40s and above that who use marijuana regularly.”
Mr Bill Barclay, the chief executive of the Tiwi Health Hoard told me his organisation and its initiatives in relation to suicide/self-harm. The Board is entirely composed of Tiwi Aboriginal people, and controls the Health Budget for the Tiwi Islands (the Commonwealth — aud the Northern Territory contributing the funds). The Board employs 84 staff including 22 Aboriginal health workers, three doctors and five nurses. He gave cvidence that (page 113):
“We've also just recently contracted Amity Services and we've just signed a $20,000 contract with then recently to provide input in regard to alcohol and drug workshops and our early experience with Amily has been very good. They’ve already tun a couple of workshops — relationship workshops for us and we intend to use them and other private organisations thai have these skills and abilities and we intend to use
’ them in the future to conduct workshops of this nature but not exclusively. You'll notice also that we brought a gentleman from Melbourne in April to conduct a workshop on suicide specifically — suicide prevention specifically. That was
regarded by all concerned, J think, as an extremely successful initiative, .
MR PRIESTLEY: How many people would have participated in that?---Some 150 - people in all attended those workshops over four days.
And how many from Tiwi islands?---All from the Tiwi Islands and all voluntary — voluntary. Those wero family — parents, members of councils. Most of those people
' would have been attending on their own —on their own volition. Some of thom were council people who were Luld to attend, but by far the vast majority were Just peaple who were interested in acquiring skills in how to deal with suicide and how to
recognise the symploms when they occur or when suicide is likely to happen.”
Mr Barclay also gave evidence that (page 119/120};
“And are there any strategies ihat you see as being effective, if not in Place now, but if they are in place it would be of value to hear of them, about dealing with alcohol and cannabis abuse ?-~My own belief is that the most positive way of dealing with this problem is through the education system and through young people. I don’t know that therc’s a great deal can be done to —in regard to people approaching nriddle age, or in their late 20s, 30s, but that | believe that our efforts and resources should be directed at the eduction system and providing as much eduction — as much information as we possibly can to young people in regard to the dangers they’ie
putting themselves at when they indulge in these activities, particularly in excess.”
And in regard to the future (page 122);
“Tn relation to the suicide prevention, I’m. asking this because — for the Corener’s P iS }
Teport, can I suggest to you that the ongoing incidents that we heard from Doctor
"Harrison that ate still happening right now, that it is far too early for any pessimism
to enter this debate and that we should still remain optimistic about the autcomes?---I
. certainly would agree with that 100%. I think it’s extremely important. I have
discussed this matter with many peuple. The question of the — general health , the gencral mental and physical health of — of Tiwi Islanders in my view, and of course this is —- this is — this is simply my view of it, has improved dramatically in the space of the jast 18 months and | believe that there has been improvements in self-esteem and are very evideat and that there will in due course — there will be improvements in the general meatal health of the community as long as some of these outside influences, such as cannabis and yropz, can be brought under better control. And I believe that overall the Tiwi Islanders are feeling better about themseives today than
they were even two years ago.
And without in any way minimising the management expertise that has lead to those, would you agtee that one of the fundamental reasons is as Doctor Harrison called it, that the Tiwi peaple owned the problems and owned the solutions?---Absolutely,
That is just so true. It is that feeling of empowerment and that they have control al
el lest these days they have total control over their own health future and that js having a marked effect, | believe, on the community as a whole and their demands lo get
control of the rest of their lives through regional government and other — other
initialives that are under way at the present time.”
Mir Barclay gave further evidence in the Inquest on 10 November 1999 and told me thal the
suicide/self-harm problems were getting worse (page 220):
“Right?---Facuse me. No, 1’m talking about the actual clinic staff who had been dealing, during the week, with several attempted suicides, following on the earlier on, and then the alempted suicides, following on the carlicr one, and then the — and the subsequent one, the one on the Friday night, another one on the Saturday night, and then for that [ollowing week there were some — at Icast seven attempts, and this had led to most of our staff having sleepless nights, and so that in addition to dealing with their own gricf, they were having to deal with these additional problems arising in the
communily. And this was becoming almost intolerable.
It was a sense of urgency that you contacted me earlier in this week?---Il was. It was partly because I didn’t feel that in my earlier evidence I had given strong enough views in rclation to the liquor situation, and ihis was partly because I felt that this was something that needed to come from the Tiwi people themselves and from the
board members and others, but I’ve had reasons to change my views on that since.” And (page 222/223):
. “MR McDONALD: In terms of as things stand today, 10 November 1999, how do you assess the urgency of the situation in respect of alcohol and marijuana in relation
. fo your health board’s efforts (o deal with suicide, atternpted suicide and in selfinflicted harm?---Oh, we would prefer something to have been done about il yesterday, Jas. month. ] mean there — there — it’s impossible to put a time on it, I—a clear —[ understand the process has to be followed in terms of obtaining the changes that are proposed, but the longer it’s delayed the morc likely there is of further
altempts and further campleted suicides and other related domestic violence on the
islands I think it — and it could possibly even get worse. The feeling, the impression that I’m getting from the reports that we are getting daily from oor staff on the islands is of continued and increasing psychosis and incidents in the immediate vicinity of the clinics and in the clinics with — with patients, and I
think that something is urgently needed — ceeds to be done.
You’ve had the iragedy of your senior health worker dying last week?---Ycs.
[Apparently from suicide]
What's the state of the staff morale dealing with suicide prevention at the
present time?--- Well, I believe that it’s an all time low.”
Dr Tricia Nagel, the Director of Psychiatcy at Darwin Hospital, told me about the noticeable increase in admissions to the psychiatric ward of the hospital of Tiwi Islanders (page 148):
“We understand that alcohol is a depressant, bul you*ve suggested here that cannabis
The dala., we've looked at Aboriginal admissions to our unit and - - - THE CORONER: Thai's the Cowdy Ward?---That’s the Cowdy Ward,
Yes?---But in arandom sample, 97 to °58 calendar year, out of 27 Aboriginal admissions, nine of these were specifically for drug-induced psychosis, and that’s what we're talking about. So the vast majority were. And the other causes, when you gathered them up, about three-quarters were to do with substance use in some way, The commonest used drug was alcohol; alcohol and marijuana came
second; marijuana alone then, and then petrel and kava.” —
And (page 148):
2t
“,., the same figures arise in that Aboriginal people have a far more common
diagnosis of alcohol or drug-induced psychosis _..” And (page 149}:
“we did look, in 1995, all of the admissions, all of the Aboriginal admissions.
90% had a problem with alcohol and 50% had self-harm behaviour, So selfharm behaviour comes through as a major problem; self-harm behaviour as an extension of suicidal intent. And now I go to anecdotal experience now.
Unfortunately, what we are seeing coming in is people who may or may not be psychotic at the time but with a rope around their neck befare they came ii and we're getting the attempts coming into the wards. So we're basically getting the in-patient sample of the community sample that’s reported by Chris Harison’s siatistics, for
example.” (page 149)
Dr Robert Parker, a qualified psychiatrist, gave evidence of his 20-year association with the Tiwi Islands. He is marricd to an Aboriginal lady from the Islands, He has recently completed (with the help of my office) a disserlativn for his Fellowship of the Royal Australian & New Zealand College of Psychiairists; the dissertation is all about Aboriginal Suicide in the Top End. All health professionals concerned with this problem should read and digest i He gave as the reason for his stady (page 184):
“Well the reason for the audit — what I was particularly concerned about were what appeared to be the recent increase in suicides in tho Tiwi Islands where Tiwi has been
further suicides.”
And significantly (page 187/188):
an
“Now you’ve ved on the Tiwi Islands and you've lived in the Tiwi community; is the phenomenon of suicide something that’s talked about and reflected upon, in your experience, amongst Tiwi people?---Well one thing that was very interesting, as I mention in the report, that [ went over to Bathurst Island, two years ago ag pari of a conference tor physicians that was held and a large number of doctors visited the community and the Tiwi health workers put up a table of the things that had affected the community over the last 20 years and I was there at the beginning of that period, in a non-medical capacity, but suicide was virtually 2 non-event in ‘Tiwi at the time, in the late seventies, it just didn’t happen. And yet 20 years on, there’s heen a significant number of suicides. But this was in ~ accompanied a lot ‘of other significant health factors in the community, such as diahetes and renal
disease. So there seemed to be a significant increase in a number of health variables,
One of which - - -
_ THE CORONER: Ii seems to be a coincidence on that timing also, with the advent -Of liquor?---Certainly alcohol - alcohol is one factor related to diabetes and certainly
. an lead to renal failure io associaiion with poorly controlled diabetes.
I mean, three generations ago, Aboriginais weren't able — it wasn't lawLul for them to drink or have liquor?--Well that was — it’s an importanl point, Your Worship, because one point that came up here — a very important point from Ernest.
Hunter’s werk in the Kimberley was that there appears te be like a 20-year gap between the — 26 to 30-year gap between the introduction of alcohol to communities and suicide. Hunter noted that in dhe Kimberley, it was in the sixties, Aboriginal stockmen were moved off stations because of an industrial award that - their wages went up, they were effectively sacked by the station awners, they were moved to towns and that was really their first contact with alcohol. And so there was a lot of heavy — a lot of social disruption on the fringes of the Kimberley town. And it was 20 to 30 years later that the children brought up in that environment started hanging themselves. And it was a similar thing with Tiwi. But I remember — sorry, T'm getting a bit emotional. I remember living in Bathurst Island during the late
seventies and it was a very intense environment, A Jot of aleohol, a lot of
er
violence and again, a couple of ycars previously that wasn’t a significant factor.
And again, it’s the children brought up in that environment who, 20 years later, are killing themsclves. So I think it has a lot to do with the early childhood environment of young people and the intcrnalisation of a lot of violence, a lot of
anger and grief.
~-- «J think it’s a lot of — there’s a lot of young people from the - that environment carry — any disruptive environment that young people are exposed to, carrics a lot of anger and grief. Young men particularly appear unable to deal with feelings related to this sort of situation. I mean, men are not encouraged to show feelings and it seems to predispose men later on, when they have a sivnificant situation, such as 4 marriage break-up or some sori of emotional stress, and in the context of being
drunk themselves, to think about harming themselves.” And (page 189/190):
“In relation to the ‘liwi Islands and Tiwi society, what do you see as the main risk factors, firstly and then sceondly, the main underlying problems that you see as having given rise to this recent phenomenon no apparent 20 years ago, of suicide and apparent infended self-harm for whatever reason?---Well must of the suicides or attempted suicides appear in the context of heavy alcohol mebriation. I think from the series that I did over that — I mean, I studied —I just did't the 2 year — the four suicides for this Inquest, but over the number of years previously, I think all, except for one, occurred in the context of serious alcohol imebriation “and then a minor psychological insult; a wife having an argument or somcone not talking to the person when they wanted ta talk. But the person was (inaudible) _tuebriated at that time. So I would think that the alcohol places someone at
significant disadvantage or risk, given the right opportunity.”
Dr Parker spoke about life education for the children as being a strategy to reduce fulure sel{-hann (page 194}:
“...d would think also there needs to be some —’m becoming more in favour of looking aé some sort of school-based intervention and trying to normalise feelings for the young people, abunt what's happening in the home environment, Aansither issue that’s happened with Tiwi cuiture: in the past the Tiwi children were
brought up by a group of people, so that they’d have a number of aunts or uncles or -
Different mentors?---That they could go to if thore was a problem with their mother.
Nowadays, because people are living in houses, the kids are poing home to their houses, parents are drunk and fighting, I mcan, they can run to other people, but they*ve also got to experience this sort of — more isolated family structure and it’s — they have less chance to talk about their feclings, develop their feelings. Pye certainly become more in favour of trying to develop something in primary or secondary syllabuses where young kids can try and normalise sume of these feelings of anger, it’s okay to feel sad about issucs. And particularly looking at young men, because that seems to be the particularly at risk group.”
And (page 198):
“If you're wanting to improve the statistics and abate the spate of attempts and the.
developing statistics in relation to the suicide; in order of priority, what practical Mmeastires need to be taken’?-—Weil [ think, again, the aleohul — there’s no doubt that binge drinking is related to most of these suicide attempts. People being inebriated and having some sort of psychological injury. I would think the community needs to basically look at the way they use alcohol and be responsible for
that.”
And finally, Mr Farquhar (for the Northern Territory) put-te him propositions with which he agreed (page 202):
“Allright. So they are the immediate strategies of alcohal reduction, counselling facilities, a women’s shelter. Long-term strategies, the 20-year strategies that is relerred to in your report, he educational strategies of promoting emotionul coping
skills, [ think, was how Doctor Nagel put it. What I’m askin g is that all of the
policies that Tiwi Health Board have taken on board: ihe educational policies and the Territory Health Services before them will be a jong lime kicking in so that the receni tragedies shouldn’t dishearten us toa much; to abandon those policies?---I think — whatever policy — it'll often be a number of years befure policies start to
work.
Tsuppose my concern, doctor, is as you know, that there have been two further deaths very recently ?---Yes - -- - which have had an obviously yery adverse effect on everybody involved, but V'TL be submitting to the Coroner that he should be calling on people to persevere and I’m seeking your support in thal?---You’te not going to achieve change overnighi, basically. It’s going to be something that’s — unfortunately — I mean, there are ways to intervene reasonable quickly with the ‘Tiwi, such as reduction of alcohol at-risk behaviour. If they agree io that. The more long term strategies, such as young people dealing with their feelings about
disruptive family life is a much more long-term effect.”
Dr Parker {as well as Mr Barclay) was of the opinion that in terms of reducing suicide/seliharra on the Tiwi Islands, that the problem of alcohol abuse had to be addressed, Unless this problem was addressed, then strategies such as “Tiwi for Life”, counselling, mental
health treatment, education and other pro-aciive programs would not be effective.
Sergeant Peter Cumming gave evidence (both orally and in a statutory declaration); his written thoughts are so relevant that I have annexed them to these findings. He told me that
about 98% of all police work on the Islands “involves alcohol”. He went on the say?
“.. Of our work generally on the islands that requires some sort of police
intervention, I would say about 98% of our work involves alcohol.
“A permanent police presence?---[’d compare it to a position of somewhere like Elcho Island which has a similar population ta Nguiu. It doesn’t have a permanent police posting there, it has an ACPO present, who is perfectly capable of dealing with
the day to day problems, simply because there are no licensed facilities on the island.
And for that reason, I believe, yes, that if there were no alcohol, you would not
require five police officers to be present on the island.
“|. 1 believe that a strategy needs to be developed to Iuwer the consumption of alcohol on the islands. It is the primary reason behind, not only suicides, but
domestic violence, .,.”
He contioued that available statistics on the level of attempted suicide/self-hatm would only indicate “the tip of an iceberg” because of under-reporting. He stated that because of historical reasons him and Constable Moore were situated on Meiville Island instead of Bathurst Island. He said {page 214):
“Now when we were over on the Tiwi Islands there was a criticism made of police in that the police were stationed in Pirlangimpi and not at Nguiu and one of the —a number of comments were made that the European — there needs to be a European police presence to back up ihe Aboriginal Community Police Officers at Neguiu.
_ What do you say in relation to that criticism?---It’s very — it’s very difficult to refute that criticism. I totally Support having police at Nguiu. There — it is currently under review by management of the police department but my opinion is that — that we are gcographically misplaced. We are not currently in a position to respond to the majority of incidents that occur within the Tiwi Islands and as a resuit of not living within the major communities the police don’t really have a feel for what is happening in the major community being Neuiu. Thete’s an idca that police should perhaps remain at Pirlangimpi and be used as support towards the peuple of N; ‘guiu allowing the people of Neuiu to rectify their own problems and when they get beyond their control to call in the police for assistance. Police aren’t always available from Pirlangimpi. We have to drive to the other end of the island. We have to arrange a dinghy in the middle of the uight to travel ovet and pick us up quite often which is exceptionally difficult to do. Quite often you can’t find somebody to bring a dinghy across and we have to rely on going the following moming. In relation to our workload, 75% of police work on the Tiwi Islands comes from
Neguiu,.”
This Inquest by itself cannot provide all of, or most of, the answers to provent or diminish
the problem of suicide and self-harm on the Tiwi Islands. However, | have endeavonred io
explore and publicise, in these findings as to the relevant circumstances of the deaths of the
four deceased, the factors which I believe underly the problem.
recommend that Health professionais, police and the Minister for Territory Health Services (and his advisers) read and take notice not only of these findings and annexures but also of the [ull reports of Dr Nagel and Dr Harrison, as well as Dr
Parker’s dissertation, all tendered during the Inquest
[recommend that the Northern Territory Commissioner of Police favourably consider locating Police Officers (in addition ta ACPOs) on Bathurst Island and within the township of Nguiu.
[ recommend that the Norther Territory Commissioner of Police favourably consider providing a school-based Cnnstable at Tiwi Island schools which have
sufficient populations to justify one.
I recommend that the Tiwi Health Board continue to receive the financial and other help it receives ftom the Northern Territory Government with special regard to increasing this help during the acule phase in relation to suicide/self-harm existing al
the moment, The “Tiwi for 1 ife” program should be augmented with further
expericneed and appropriate counsellors and resourcing.
Tcecommend that the Northern Territory Liquor Commission consider as a matter of
with a view to restricting hours and days of trading as well! as closing the “clubs” during the annual June “bush holiday”. Tn this regard I recommend the Commission sludy the transcript of evidence adduced al the Inquest as well as documentary exhibils and take immediate steps to consult with the newly elected President of the
Neuiu Town Council (Mi Barry Puruntatameri) and other Elders.
other witnesses who spoke about such measures.
some did not (being those with spikes).
Dated this 24th day of November 1999.
e
7UIU, BATHU LAND, OF: No. 129/98
No. 130/98
Neo. 182/98
No. 203/98
David Farquhar Cridlands Telephone: 89 430 400
Reference: 99093739 11361685
On 3 March 1999 fhe ‘lerritory Coroner announced he would hold an inquest inta the four deaths in an attempt to ascertain what can be done to reduce the number of deaths by suicide on Bathurst Island.
Bathurst Island, with 2 population of about 1470, has a depressingly high suicide rate. There have been 10 deaths by suicicle since 1991, including 2 deaths in 1997, the 4 deaths in 1998 that are the subject of this inquest, and. 2 further suicides since the commencement of the inquest on 16 August 1999.
The Tiwi Islands also has a very high rate of attempted suicide, and self harm.
Between the commencement of the inquest and. tts resumption in November there has been an upsurge in atternpted suicides and incidents of sulf-harm.
A senior health worker at Nguiu was one of the 2 people who committed suicide at the beginning of November. This death has caused the morale of the Tiwi Health Board staff to drop te an all time low as they fy and cope with their own grief as well as intervening in more and more crises.
The Police originally requested that the Coroner examine the sudden upstirge of deaths on Bathurst Island, within the conlext of an increasing suicide raie throughout the NT and Australia.
The Northern Territory instructed its lawyers to listen and to learn, and: {a} to pass on the Nguiu community’s concerns to the Government; and
(b) to assist the Coroner to provide the Government with a considered report on how to respond to the increasing numbers of suicides and attempted suicides.
The Northern Territory hopes that this inquest:
rather than talking about a community in crisis,
will have a positive focus for the Tiwi community,
will reirforce the efforts towards suicide prevention made so faz, and
« will encoucage the energy, stamina and hard work needed to go further to respond lo Lhese premalure and distressing deaths,
The incidence of self-harm, and death by suicide for yourg people is increasing
throughout Australia zt a frightening rate, particularly in the regional, rural and remote communities.
~3-
Because of the cultural, social and historical differences between various Australian communities, there is no single strategy of suicide prevention that will work Australia wide.
The experts suggest that the most appropriate methods for dealing with suicide prevention, or life promotion as it is often expressed, must come from within the community itsclf, and must not be imposed from outside.
Accordingly, the Coroner attended at Bathurst Island to listen to the residents’ concerns and suggestions. The inquest heard much evider.ce about the factors leading to people harming themselves, with alcohol and cannabis both referred to by most witnesses.
The issue of alcohol abuse has raised a fundamental difficulty relating to self determination, There are strong suggestions from within the Tiwi community and from outside that the culture of the men drinking beer at the clubs is so strong that the Tiwi people themselves lack the will and capacity to take effective stcps fo resolve the enormous alcohol problem on the Islands.
Police, medical and social evidence places alcoho) abuse as the fundamental direct cause of the high suicide and attempted suicide rate. There have been calls for a tough line to be taken by the authorities based outside the Tiwi Islands. Witnesses have called for further restriction on the already limited sales of beer, and have demanded policing of the Clubs ta reduce the prevalence of breaches of the liquor licenses, Yet the same witnesses agree thal lhe commumity itself has the power to take these steps and shut the clubs altogether if they wish, but the community has not done so.
There has been extensive consultation, both in Nguiu and also more generally in the Top End of the Territory for some years on suicide prevention.
Those talks have led fo a number af Tiwi adapted and implemented programs that
the Tiwi people should be proud of, and musl persevere with, as leading the way in combating self-destructive behaviour.
There were extensive police investigations inte the four deaths. Senior Constable Anne Lade coordinaled the Coroner's investigation into each of the deaths, being:
fa} Gary Peter Tipungwuti — born 2/2/80 at Royal Darwin Hospital, died on 21/8/98 at Neil
The deceased was an 18 year old male, living with his parents. He hanged himself at the family home shortly before 2.00 am on 21/8/98. He was discavered by his father, who called the deceased's eldest brother to lift the youth down. There were no signs of life,
The deceased worked under the CDEP scheme, gardening end mowing. He is reported by his family to have smoked cannabis regularly but onty to have
“3.
consumed beer oceasionally. There was no alcohol or cannabis in his system at autopsy.
A possible teason put forward by the family for this deata by suicide is that the deceased had asked his parents for money to travel to Croker Island for ceremonial purposes. He was very concerned about what may be going to happen at Croker Island. Very little information was disclosed to the inquest as to why a Tiwi Islander, where there are no initiation ceremonies, would he involved in such ceremories at Croker. The family was unable to give him all the money he needed for the airfare.
The deceased’s brother had seen. red marks around the youth's neck the day before his death, and had asked him if he had tried to harg himself, but nothing apparently came cf the talk.
ib} Raymond Patrick Kerinavia — born 19/8/72 at Royal Darwin Hospital, died on 21/8/98 at Nzuin.
The decuased was a 26 year old male, who was employed asa fill time truck driver with the Nguiu Couneil. Ee lived with his gi rifriend /de facto wile, in her mether’s house. His girlfriend's sisters also lived in the house. He had become very drunk at Nguiu Club. After returning from the club he had argued with and ther assaulted his pirliriand who left the hoase. When she returned at about £1.50 pm she found that he had hanged himself in thei bedroom.
The deceased lived next door to Gary Tipungwuti and was aware of that young man’s death by hanging that morning.
About 18 morths previously the deceased had tried to hang himself from a tree near the cemetery and his girlfriend ‘rad to get a knife to cut him dowa.
The deceased was intoxicated (197%) but toxicology disclosed no evidence of him smoking cannabis on the day of death.
(cl Noelene Puantulura -— born 2/3/76 at Bathurst Island, died on 28/10/96 at Nein.
The deccased was a 22 year old female, who fell from a power pole at about 8.15 pm on 28/19/98. She had returned from the Nguiu Social Club to the family home, where she lived with her father, her younger sisters and her 7 years old daughter.
She had argued with her boyfriend and told her family that he was leaving ber, and she was going to kil herself. She climbed the power pole, and refused her family’s pleas to climb down. A crowd had gathered at the base. There were fears that she may electrocute herself sn the power was turned off, leaving the scene in darkness.
She remained up there for about 15 minutes. There are different views expressed by the eyewitnesses. Some said the deceased remained at the top of the pole and then let go her hold. Others said she went to sleep and fell, and olher wimesses reported to police that she started to climb down and she fell from the pole. No one has stated that they saw her jump.
As the deceased had a blood alcohol concentration of .146%, it is quite possible she simply went to sleep ar.d fell.
The deceased sustained multiple injuries including a fractured spine at T1/2 and at LI, numerous fractures to both legs, and a ruptured liver. The injuries were fatal.
The deceased had previously expressed thoughts of suicide to her father, in speaking
_-of hoping to soon join her deceased mother. In February 1995, a doctor had noted _
that she had suicidal ideation, but displayed no real intent.
In the light of the differing views of witnesses, the Coroner should not return a finding of death by suicice but should make a finding of death by accident.
(dj Johr. Gerald Orsto — born 4/2/66 at Bathurst Island, died on 30/11/98 at WNguiu.
The deceased was a 32 year ald male, who hanged himself at the back of his brother’s residence. The deceased usually lived at his uncle’s house.
The deceased was employed asa bouncer at the Nguiu Social Club. On the evening 30/11/98, alte> having some drinks al the Club, the Ceceasecl went home, and then af about 11.15 pm visited a fiend, wanting to talk. The friencl was too tired; so the deceased went to his brother's house. The brother and family were asleep and unaware of his visit. The deceased’s body was discovered by a neighbour shortly after 11.30 pin,
Cc
The family and authorities were unaware of any reason lor hs suicide. The deceased had separated from wife in 1992 and although he missed his 3 chifdren he had noi seen his wife or the children for i2 months prior to his death. He appearect to his family and friends to be coping well.
The deceased had a previous history of self-harm. Om 15 January 1990 he had sustained a selZ inflicted shot gun wo.nd to his upper arm, and reportecl to the doctors that he was having problems at home with his wife. There are Rural Health Centre notes of the shooting, but no apparent referral for counselling.
The deceased had a blood alcuhel level of 199%, and no residues of cummabis were discovered.
3 NT Statistics /Comparison with Elsewhere
The Coroner’s Office has maintained statistics on the number of suicides in the northern regior. of NT which have been provided to this inquest disclosing:
1991 -15 (1 Aboriginal and 14 non-Aboriginal} 1992, - 17 (7 Aboriginal) 1993 - 23 (3 Aboriginal} 1994 ~ 14 (2? Aboriginal) 1995 - 21 (J Aboriginal} 1994 + 34 (4 Aboriginal) 1997 ~ 26 (6 Aboviginal)
ua
1998 - 37 (12 Aboriginal)
The inquest has alsa received evidence from Doctors Nagel and Parker of Territory Health Services, and Lr Chris Harrison of the Tiwi Health Board on the available igures of NT suicides.
The study by the Victorian Coroner’s Office af suicides in Victoria showed an increase in suicide and serious self hann tates of 3U% in that State, with a reduction in shootings and a dramatic increase in hangings.
The national suicide rate is 13.1 per 100,000 {22-23 for males and 5 for females) however there ave variations in definition of suicide and data collection in each ate and Territory, Suicide may be underreported as death by drug overdose and death by misadventure.
Las
Male suicide rates are higher than female in all age groups. Rates are higher over the age of 75 years - but there are low numbers in this ege group. Suicides in younger men tripled between 1966 and 1996. They ave still rising in young adult males - but not in youth.
The NT rate of suicide for 1997 is 34.8 per 10U,U1N population. The Coroner’s Office data suggests that the 1998 rate is even higher. This much higher rate parallels recent findings from Queemsland communities as well as indigenous commnrunities overseas (e.g. Maoris in NZ, and Inuit in Canada}.
The most common method of suicide chosen by Aboriginal people is by hanging. Dr Parker discusses the significance of this method at p. 41If of his dissertation on Aboriginal Suicide. Mr Maher expresses views that in addition lo easy access to hanging material, there is an aboriginal significance in death by hanging since the Royal Commission into Aboriginal Deaths in Custody.
Dr Harrison’s records disclose a depressing litany of attempted suicides, episodes of serious self-harm, and suicidal ideation among the residents of Bathurst Islanc..
4, The views of the Neuiu Community The inquest commenced at the Nguiu Counci!, Bathurst Island on 16 August 1999,
The Coroner made an opening statement to the community members that he was holding a joint inquest into the 4 possible suicides because he was concerned that insufficient attention was being paid to the mental, emotional, and spiritual health of Aboriginal people. He advised that he did not want lo cause any distress to the families or the Tiwi community by his invelyement, but the issue of why the people had committed suicide needed to be addressed for the benefit of the Tiwi people in the future.
The members of the Nguiu Community Government Council, particularly Danny Munkara, Esther Babui, Frances Xavier Maralampui and other residents of the Neuiu community spoke ina free ranging talk with the Coroner and Mr McDonald.
Cencems wete expressed about the changing way of life; the loss of self discipline; the Inss of traditional values; the abuse of alcohol leading to domestic violence; and the widespread use of marijuana by the younger people ‘eading to demands for money, loss of vitality and unusual behaviour.
The Coroner and Mr McDonald then mef privately with the families of the deceased, as the families did not wish to give evidence or speak publicly. The families told of their fears that marijuana, “gunga”, was a serious problem that needed to be addressed. They spoke of their sadness and bewilderment as fo why the deaths had occurred.
Barry Purunta‘ameri, a former President of Nguiu Council stated that attenclances at Church were down in the last few years. He believed thal too much aleohol and cannabis were causing family relationships to break down. He Jamented the apparent change of values in young people.
Mir Puruntatameri gave evidence again in Darwin calling for a stricter regulation of alcohol consamption. Whilst itis within the Liquor Commission’s power to further imit the opening hours and take away limits of the Nguia Social Chub, the community itself needs to enforce any such regulation. He does not believe that the majority of men who drink at the Club will ever vote for a stricter enforcement of he current restrictions. " *
Other community members suggested that their children were bored, and were influenced by what they saw on television, to the extent that a number of young boys copied American Negro fashions.
It was suggested that the Coroner should hear from some youngsters ta find out their views on why young people are killing and hamming themselves. The 2 schools then arranged that some classes would attend at the Recreation Fall the next day to speak to the Coroner in the absence of the adult community.
On 1? August 1999 the inquest heard from Constable David Moore, based on Melville Island, and the Aboriginal Community Police Officers (ACPO), Kim Kerinaiia and Silverius Tipungwuti, about their perceptions of what might have caused a leap in the number of people killing themselves.
Conatable Moore reported that funerals are a very important Tiwi ceremony, usually involving a large part of the community. He had spoken to youngsters who scemed envious of the attention given to the deceased, and they suggested that they would lixe te he Incking down on their own funeral.
Constable Moore confirmed that cannabis was used extensively by the community, and such use was not restricted to the youngsters. Cannabis abuse seamed te him to make people behave in abnormal ways, but it was not, in his view, related to domvstic violence. The police officer believed that alcohol abuse remained at the very cote of the community problems.
The ACPO's were relatively shy and unforthcoming in puaiic.
A class of female students met with the Coroner and Mr McDonald in the Recreation [all and spoke of loneliness, family violence, (particularly after the Club
shut in the evening) and the general commumity acceptance of smoking marijuana, as the likely causes of peoples hurting themselves.
The boys were less forthcoming, but confirmed the excessive use of alcohol and marijuana aga cause of family problems.
A Statutory Declaration of Mr O”Sullivan dated 8/11/99 advises that he has stopped living on Bathurst Island since the inquest commenced there and is now employed by the Tiwi Health Board as Youth Services Manager. The statement reinforces the value of the Recreation Hall asa place to house various community activities, and of the need for kids to be involved with sport and community groups such as the recently formed Tiwi Scouts. Mr O'Sullivan, having lived in the community for 16 months, expressed concert: with the following problems;
alcohol consumption, especially binge drinking
use of cannabis and an apparently resultant lack of self-motivation
« low self esteem, exacerbated by a lack of sport and recreation facilities, combined with access to 3 TV channels, showing lifestyles with opportunilies vastly different to that available to Tiwi Islanders.
Denise Luta has had an extensive involvemen: in issues of suicide prevention, commencing with her empluyment in Territury Health Services, and continuing as
the Life Premotions Officer, Tiwi Health Board. She made a statement to the Police and te the Coroner:
¢ Issue of suicide nas only been seen by Tiwi's as a problem in the last few vears
At Youth workshop in Apri! 1999 the 1!- 17 year old kids vated suicide qn behind alcohol/drugs. Relationships, anc. family fighting
Alcohol and cannabis played a part in 2 of the 4 deaths
When employed at Mental Health she spoke with people who had attempted suicide, some people did it for attention, and would make the attempt where people were who could stop them, or they would tell someone else they were going ta attempt suicide
® Relationship problems, Le. boyfriend is leaving her, ur fights wilhin the family
Overcrowded livirg conditions on Nguiu, people cannot go and have some peace and quiet somewhere
Alcohol and marijuana can causes people to look at things differently. Marijuana is prevalent and its use is increasing
Mental illness e Low self esteem
« Aclash of cultures
On 18 August 1999 af Darwin, Dr Chris Harrison, medical practitioner of the Tiwi Heaith Board gave evidence and expanded on the statistics anrexed to his statement.
Dr Harrison had collated the -eported acts of threatened suicide, acts of selharm and completed suicides since 1 January 1997.
His evidence of the patterns of persons who have attempted or completed suicide suggested the following factors:
» Alcohol abuse is widespread, and appears to be a focal point for family disputes, domestic violence, and is a depressant that was involved in 3 out of the 4 deaths
« Relationship Problems and Domestic Violence « Mental Health
Overcrowding - there is nat enough Aousing, people cannot go and have some peace and quiet somewhere ‘
Blackmail - attention seeking behaviour ® Family reasons, loneliness, lack of self esteem
Unemployment has been suggested as a background problem. The evidence for the 4 deaths under specific investigation is that one of the victims had been working with the CDEP doing ga:cening. One was employed full time by che Council driving a tuck, working on the roads. One was working at the restaurant/take away shop; and Tiwi Design employed one as a screen printer.
The quality of the employment is not known, nor is there any evidence of the range and availability of employment on Bathurst Isiand.
© Difficulties in education, with some dysfunctional families not sending their chiidren to school
® Botedom in the community, particularly during the Jater hours, when the Club and the recreation hall are closed.
Dr Harrison stressed that there is no sing'c factor or issue, but a combination were put fo-ward by most interviewees.
. Evidence of John Maher
Mr Maher, a highly qualified and experienced psychiatric russe and currently manager of THS Mental Health Team provided a statutory declazation setting out
“Je
his. close involvement with the Tiwi Islands. He and Pius Tipungwuti interviewed every person who was reported as having attempted suicide or serious self-harm.
The continuing and common four factors that he observed were:
(a) Violence, particularly domestic violence and abuse;
(b) Alcohol abuse across the whole comununity affecting the mental health of all: (ec) Cannabis abuse;
(a) A cultural clash between the colleclivist philosophy and the individual
philosophy.
Mr Maher expressed particular concern that Tiwi women can be subject to extreme violence against them. The women may be victims of their husbancls, their kusband’s family, and ‘heir own family. They simply cannot win in a violent relationship, Most victims will not apply for restraining orders for fear of reprisal.
The court might issue restraining orders but these orders have a limited - value
because the community generally will not support these women.
‘A combination of the evidence taken during the inquest with the statements taken by the Coroner’ investigators show the following recurring issues and factors that the community beliéve contribute to the high suicide rate. _
Severe and widespread alcoho: abuse
General unrestricted use of marijuana
Relationship Problems
Family reasons, loneliness
Domestic Violence
Mental Health
Overcrowding — not enough housing
Blackmail — attention seeking
Sniffing petrol
Unemployment
Feclings of loss of culture and identity
-[0-
oom
Los of traditional values Difficulties in education
Boredom
Dr Trish Nagel and Dr Rob Farker both provided assistance from the peychiatric perspective to the Coroner. Dr Parker has written a dissertation “An Audit of Coronial Records for the Top End of the NT comparing factors in Aboriginal suicide against other suicides in the tegion” which provides an extremely useful text for the NT to consider when preparing its suicide prevention strategy.
The study of suicide is a key feature of the discipline of psychiatry and related disciplines in mental health such as peychology, social work and psychiatric nursing.
It is also the province of health practitioners in general, anthropologists, social planners, criminologists, public health practitioners, and environmental health practitioners. Jt has become an important facus for lecal government, police, and correctional setvices policy development. It is an issue that warrants a holistic
approach, starling at the grass roots level of the community.
Dr Nagel stated that in her experience alcohol and cannabis couldn't act alone to cause suicidal behaviour. There is always a combination of factors that will take someone out of their safety zoric.
The recognised patterns of people at risk reflect why the NT has such a hipa suicide rate. The NT has an extremely high rate cf substance abuse, with a higher than national average proportion ef people living in rural and remote areas, a high proportion of indigenous people, a diverse range af ethnic backgrounds, and for many, a lack of family support.
Dr Nagel gave evidence that the many risk factors for suicde may be categorized inte biological, psychological and social background factors.
Biological causes are current mental illness - in particular depression and psychosis and substance use disorders, as well as genetic factors.
Psychological causes include psychological stress end distress, despair ard hopelessness, ‘copy cat’ behavior, loss of successful role modeling behaviour for dealing with stress, stigma associated with help-seeking behavior, and social alienation.
Social issues contributing to risk are unemployment, poor housing, and socioeconomic disadvantage.
People at risk are those who are: « = Socially isolated
-li-
‘ Elderly
e Male
. Have access fa mear e.g. firearms
a Have assoclaled mental illness
« Have associated chronic physical ilncss
« Experierce a recent relationship loss or break dawn
. Live in a remote /rural location
a Have family risk factors such as mental illness, substance abuse, marival discord.
1a, Aboriginal Suicide
The Coroner is referred to Dr Parker's dissertation which concludes that suicide has different features for Aboriginal and non Aboriginal people, and that there was a contagion phenomena present during the recent and perhaps ongoing suicides of people at Nevin.
The specific contributing factors to Aboriginal suicide are many and varied. The -Canadiaa Royal Cumunission (1995) stated that Aboriginal suicide and self harm behaviour was the result ef a complec mix of social, cultural, economic and psychological dislocations that flow from past to present.
Specific factors in Aboriginal communities are:
« Cultural Change
© High Incidence of violence
« Unemployment
» Substance use
« Poor access fo services
» Lack of culturally appropriate services
Dr Parker gave evidence that the early childhood home environment and education is fundamental to whether a person is more susceptible to comuritting suicide some 15 — 20 years later. He suggested there is a definite link for suicide victims, between aleohol abuse and domestic viclence in the home, then « gap of a number of years growing up, then the person becomes involved themselves in alcohol abuse and domestic vielence and fmally committing acts of self harm or the ultimate act of suicide,
Dr Parker has extensive first hand experience of the Tiwi Islands, originally as an Arts and Cracts officer, then as a doctor, and now as a psychiatrist. He believes alcohal abuse is the first and foremost factor in the problems that the Thwis are now facing.
Ilis studies tevealed tha: almost all suicides (only one exception was reported) on the Tiwi Tslands result from heavy incbriation, followed by a minor psychological insult.
Because of the 20 year lead in period, the abuses of alcohol a genezation ago have permeated the culture te the extent that everything revolves around the men drinking beer at the Club.
Or one level the Tiwi society is very harmonious, progressive and creative.
However he suggested that in dealing with the overwhelming alcohol problem, the Tiwis lacked leadership. The community is not taking responsibility for the alcohol abuse, and it needs to.
Dr Parker suggested that because almost all crime and trauma type injury on the Islancs result from inebriation, all of the social chibs should be shut for a period when there is a murder or serious assault or motor accident etc. So that the community understands what is happening and is given a period to get over the tragedy without everyone gettirg drink and exacerbating the problem. He pointed pout that when ‘he Club is shut, the families are more harmonious, and the children are given a reapite.
He suggested for an immediate response ta the issue of suicide and self harm, the community should: :
L shut the Social Clubs for longer periods, particularly the Bush Holiday and for some days during the week, and after tragedies
4, Introduce school based intervention to reinforce positive lilesty1e education and anger and grief management.
Mr Munkaca, the President of the Neuiu Community Council, lold the inquest of positive sleps being taken by the Council to encourage the young people to be active, playing games and sport. The Council nas budgeted for a 25-metre pool and a trail bike track to be consLeucted by June or July 2000, The Council members were looking at proposals for an oatdoor basketball court, and a tennis court. An Indigenous Scout Troop was being established under the vatrenage of the Govemor- General.
Mr Munkara also informed the Coroner that the Council had brought in new rules imposing penalties on people who deliberately try and ‘Aarm themselves. A notice that was sent to all residents advises those persons who hurt themselves anc. their parents that they will be banned from the Club, which is the only place that sells beer, for a week to a. month, and they wil. be fined.
The senior women at Nguiu told the inquest how a Safe House is needed at Nguia, as women who were the victims of domestic violence sometime needed a shelter
but thal meant being evacuated to Darwin. This departure from the com=munity is usually too big a step for the victim to take.
Johr. Maher of Mental Health Services aiso stated that a ded icated domestic violence unit basecl al Bathurst Island would be mest beneficial. People with training in dealing with domestic violence issues can raise the community awareness and show fae victhns that chere is an escape from such violence.
Constable Moore suggested that increasing motivation could reduce the self-harm rate amongst young people, and recommended:
« Increasing youth activities such as film nights, blue light discos; s Introduce schoul-based constables; « Introdtice life and drug education classes in schocls;
» Divert extra policing for drug enforcement to cut down on the transport of cannabis from Darwin to Nguiu;
Constable Moore waa positive that the Tiwi For Life initiative was being successtil in helping the community change its direction, te reinforce the Tiwi idertity.. = *
The Tiwi interpreters, Anita Ullungura and Valeria Munkara, told the inquest of the value of reinforcing the Tiwi identity and heritage. They spoke of the School Museum where the kids learn about the Tiwi culture and legends. Ai Tiwi Design the Islanders’ skil!s in painting and making artifacts are practiced and improved.
The final person to speak with the Coroner at Nguiu was Damien (YSullivan, who was then the Nguiu Community Council Sport and Recreational O-ficer. The Coroner learned that the Recreation Hall had been revamped into an indoor basketball court far the kids, and a weighis and exercise room for adults. The hall is well patronised, with often 200-300 people gathered on occasions, to play and watch sport and videos. Mr O’Sullivan is looking forward to the installation of the swimming pool to provide more diversified activities, although he had hoped the pool would be Olympic length, namely 50 metres, rather than the 25 metres that had been decided on for reasons of cust.
Li. Dealing with aleohol abuse
The women in the group who gave evidence at Nguiu, with some men’s support, suggested that the Nyuiu Social Club should be shut during Bush Holidays, when the families went bush together, hunted, fished and taught the children traditional Tiwi skills.
For the fast two years the Club has remained open, and a number of men have refuged to go sush because they wanted to drink instead. This nas led to problems with children not going bush or being at school during that time, adults not working, and too much drinking. There had been votes to close the club, but the majority of men, outvoted the women to keep it open. I: remains open 6 days per week from 4.00pm to 7.D0pm.
-]4-
The Corener heard fram David Rice, the Registrar of the Liquor Commission, details af the conditions of the 4 licenced clubs on the Twi Islands, namely that they are open for 3 hours each day except Sunday to sell beer for consumption on the premises. Milikapiti also has a take away licence limited to 6 cans of beer per person.
Mr Rice alsa provided consumption figures showing that the Nguiu Social Club sold 206,163 litres of full strength beer and 10,391 litres of low alcohol beer per annum. He also provided the consumption figures for the other 3 clubs.
The Liquor Commission issues licences according to the wishes of the community.
ITe advised that there had been occasions when the Commission received calls for one of the clubs to shut on Bush Holiday or at some specific times.
The Coroner received a heartielt but moving Statutory Declaration from Sheridan O'Leary who has worked as a Registered Nurse in Aboriginal Communities for 7 years, with the last 4 years with the Tiwi people. She is now the Projeck Officer for the NT Coordinated Care Trials. She referred the ease of acceas of illicit alcohol and to breaches of the liquor licensing conditions. She te’ated her experiences af working with the Milikapiti community as dealing with an epidemic of desression caused by alecho! abuse and associated violence.
Sergeant Peter Cummings of Pirlangimp? Police Station gave a lengthy statement: to the Coroner setting out his views on the extent of the attempted suicide ancl. suicide problem, and police activities on the Islands. In a startling figure he estimated that 98% of police work on Tiwi is directly ur indirectly related lo alcohol problems.
Almost all crime ard domestic violence is apparently either alcohol or cannabis related.
Mr Barclay gave evidence fot a second time, during the resumed hearing in November, that the situation cf drinking and suicide attempts had se ceteriora‘ed since August that the Medical Board staff could not cope and needed outside assistance from THS. He made an impassioned plea for the Liquor Coramission fo ake immediate action to deal with problem drinking because the situation on the Tiwi Islands was out of control.
He maintained that excessive alcohol is consistently being teperted by the Tiwi Health Board staff as the primary cause of the attempted and completed suicides. Yet the community cannot police its own clubs and is so stressed that it cannot take the necessary steps to reduce access to alcohol. He rejected the Liquor Commission's slance of reflecting community wishes as perpetuating the problem and called for further restrictions and far the Cammission to enforce the Hcensing conditions.
Mr Puruntatameri, a former President of the Nguiu Council, and now Liaison Officer for TIIB gave evidence that he had met with other elders of the community, with THB staff, ta the Vice President of the Council, and has been approached to stand for the Presidency of the Council in elections to be held on 16 November,
He called for the following immediate action to reduce the number of attempted suicides:
« Close all 4 licensed Tiwi clubs for Bush Holiday ® Prohibit all take away beer sales from ali outlets
« . Close all 4 licensed clubs on Tuescuys, Thursdays and Sundays
¢ The Liquor Commission or Folica to enforce the licensing laws curren:ly being fouled by the ehibs
2 Police Officers to be permanently based at Nguiu
One of the 2 Polire Officers currently based at Firlangimpi to be based at Milikapiti.
13, Tiwi [fealth Board
The Board comprises senior Tiwi people only, and delivers all primary health care to the Tiwi Islands. The Board is developing programs and structures to respond to the health needs of the Tiwi people.
This is particularly important for suicide prevention strategies, which need to encompass social, cultural and economic issues as well as a medical ane psychological response.
The programs in place will take some time to show a marked invsrovement, ‘because they are fundamentally educational as well as preventive. The strategies néed the ongoing support of the community, which in turn needs the ongoing resources support of the Northern Territory and Commonwealth Governments.
Bill Barclay, the Chief Executive of the Tiwi Health Board told the Coroner that the Commonwealth and Northern Territory governments were looking at ways of Improving the delivery of health care to Aboriginal communities.
In response to a proposal that there be Aboriginal Coordinated Care trials, at a meeting in November 1997, senior Tiwi people interested in taking on the responsibility for managing health care told the Commonwealth and Northern Territory Governments they would do ao if they had full contral of finances.
The liwi Heatth Board commenced on 1 January 1998, funded by a pool, being cashed up Medica] Benefits Scheme (MBS) and Pharmaceutical Benefits Schemes (PRS) averaged payments, together with the Northern Territory contribution of the cost of running the 3 community health centres and the visiting medical and health services.
The Board has a budget of $4.8 million from the Commonwealth and Northern Territory Governments. This sum includes ame additional payments for specific programmes; for example the Territory Health Services, Mental Health Services Branch initiated “Tiwi fur Life”.
Mr Barclay believed the Health Board has been successaul right from its inception and stated the success is based on the level of funcling that has been made available 70 it. He thought the Board would survive the current crisis brought about by the tragic suicide of a Senior Health Worker and the looses of health scaff.
ss,
Senior Tiwi pecple make up the Board which employs 84 staff, inchiding 30 CDEP workers, 22 Aboriginal Health Workers, the equivalent of 3 doctors, 5 nurses and 5 administralors.
The Board's initial priority was chronic diseases such as diabetes, rheumatic heart disease, renal disease, and nutrition, hygiene and mental health.
The issue of suicide has only been seen by the Tiwis as a problem in the last few years. The members were puzzled as to why people were hurting themselves. The Board purchased the Mental Health Programme from THS. The members felt that suicide prevention work had been submerged by the demands for mentel health services, and it was decided to separate the related issues.
Initially only one Tiwi person, Gibson [lortiminni (Farmer) was working on suicide prevention, paid by Milikapiti Council, ard funded by a Commonwealth grant through Charles Sturt University of Wagga as part of the National Suicide Prevention Project.
The Tiwi Health Buard was not involved and was concerned the project was underresourced, with Mr Gibson getting insufficient support and receiving inadequate training.
Funding of $70,000 from the Commonwealth National Suicide Prevention Project was redirected to the Tiw! Health Board which employed Dee Dee Luta, (previously with THS Child Welfare} on a full time basis, and Gibsor. Illortiminn: part time to work on suicide prevention.
In addition te employing Ms Luta full time and Mr Farmer part time, the Board purchased 30% of Jolin Maher’s time [rom Rural Mental Health Services of THS. Mr Maher had considerable expertise in mental health matters and was well known to the Tiwi community through his regular and extensive visits.
The Board initiated and contrued a number of existing THS suicide prevention programmes, such as:
® Organized a workshop in April 199¢ by Barry Taylor from Melbourne on youth suicide with a more sociological perspective than clinical one, at which 150 Tiwi people attended, on a voluntary basis.
® Ms Luta and Mr Farmer attended the National Suicide Conference in Melboume
® Developing sts of supportive contacts to talk to if a person is sad ar in crisis
oh power poles in those centres, with only belated interest from PAWA ard partial success. —
oLl?-
#¢ The Governor General visited in June 1999 and agreed ta sponsor the commencement of indigenous scouting activities, with the Board being involved wit the interviewing 12 young men for training as scout leaders.
« The Board as taken over the former Norforce building, which will become the centre for crisis intervention activities. These will include counselling available up to 16 hours per day, drop in and refuge facilities,
Mr Barelay told the Coroner that the Tiwi Health Board had not completed the planning for the counselling facilities, and would require additional funding for such positions. He advised that the Board would be putting its proposal to the Commonwealth to seek $300,000 out of the $39 millior. promised to the states and territories for suicide prevention.
The Tiwi Board takes its responsibilities very seriously, being aware that their actions, as part of the coordinated care trials, will be the subject af close scrutiny. The steps taken by the Board for each of the programmes were:
Identifying and measuring the health related problem;
Establishing the priority to be attached to that problem;
ascertaining the options for responding to the problem;
obtaining/ diverting Emancial and other resources to the agreed response; 5} implementing the response;
6} subsequently evaluating the response and measuring the problem.
Mt Barclay said that the fandamertal Tezritory Heallh Services and Tiwi LHealth Board approach was to emphasise Life Promotion, rather than Suicide Prevention, to avoid reinforcement and copy cat actions. Because these prougramunes were educational, and primarily focussed at younger peuple, they will require a lengthy time to analyse their level of success.
Dr Harrison, was supportive cf the programmes continued or initiated by the Towi Health Board. He was concerned that:
The use of cannabis is still not widely challenged in the community;
There is ro drug education programme for the children;
©. There are insufficient mental health resources available to service the Tiwi community
Dr Hartison believed that there nad been an improvement in the delivery of health care secvices, since he commenced work on Bathurst Island in 1996, and when the Tiwi Health Board was established. He said it was particularly important that the community must devise and implemnent its own public health programmes.
Mr Barclay agreed with Dr Harrison's evidence that additional alechol, drug and life education programmes were needed, perhaps to he pursued through the NT Education Depaztment for Melville Island and the Catholic Education System for the schools on Bathurst Island.
Michael Martin, Deputy Secrelary of Territory Health Services gave evidence an 19 August 1999, and his detailed statement was tendered. Mr Martin set out the respective health responsibilities of the Commonwealth and the Northern Territory Governments, and the financial and departmental background ta the current system of delivery of health services. He informed the Coroner of the current actions being taken by the Northern Territory to combat the rising rates of self-harm and suicide:
Territory Health Services (TIS) are working in accordance with the First National Suicide Strategy in conjunction with the Commorwea.th and other States and the ACT. A National Action Plan for Suicide Prevention is being developed. A Life Promotion pilot project is being conducted by THS utilising funds provided under this national initiative. This project consists of 2 teams (1 based in Central Australia and 1 based in the Top End}. Each team consists of an Aboriginal Mental Health Worker areal a non-indigenous Mental Heaith Professional. Their role is to work with individual cor munities to assist them to develop and implement strategies that address their issues aboul youlh suicide. This community development approach empowers communities to take appropriate responsibility for dealing with youth suicide, and developing strategies that address their parlicular issues.
THS has multiple roles in relation to the Tiwi Coordinated Care Trial. The Department is co-sponsor of the trial, in partnership with the Tiwi Iealth Board (THB). Co-sponsorship has involved:
creating the concept, and negoliaiing for Commenwealth trial funding # facilitating the establishment of the Tiwi Health Board, and supporting its ongoing deve_opment
development of best practice cate plans
THS was the primary provider of primary health care services to the Tiwi Islands prior to the conumencement of the trial. The Territory Health Board has taken over the management of the majority of these services. The THB is able to purchase services using funding previously spent by the NT and Commonwealth Governments on the Tiwi population. THS continues to provide puble health services in support of the Tiwi For Life Program, emergency evacuation services, and allied health services.
oN
THS contributes some $2,055,000 per annum to the Tiwi Health Board that waa previousiy spent by [HS in providing most of its primary health care services to the Tiwi Islands population. This sum excludes THS budgets for Tiwi Aged & Disability and Family & Children’s Services, which are still provided by THS.
14, THS action on suicide prevention on Tiwi Istands
4993 Commencement of two part time Aboriginal mental health workers
1995 Partnership deve:oped between John Maher - community psychiatric nurse and Pius Tipungwuti - Aboriginal Mental Health Worker aiming to deliver a ‘two way’ mental health service model. ,
1996 Evaluation of this service recognized the problem of ‘young men trying to kill themselves’.
1997 Commencement of a trial project addressing suicide prevention in collaboration with Wollongong University.
Members of the Mental Ilealth Team - John Maher and Fius Tipungwtti, and supported a steering committee by both Family Youth & Community Services (FYCS) and Family and Children’s Services (FACS) siaff on Bathurst Island.
The project resulted in a series of community workshops.
Six workshops by Professor Ray King - a specialist in youth suicide prevention - were conducted on the Tiwi Islands.
A further series of workshops were conducted by Ros Mortegue - a specialist Adolescent Psychologist from Sydney.
A series of life promotion and suicide risk awareness workshops were then conducteci by the mental health teen in collaboration with Gibson Parmer targeting the Men’s Drop in Centre, councils and schools.
Two more Tiwi conferences have been conducted since 1997,
4, The Bathurst Island Men’s Conference was requested by the community. ‘Ihe theme was life promotion through culture, and proceedings and recommendations from the conferer.ce were giver. to the council and the Tiwi Health Board.
1997 - 1998 Darwin Rural mental health team implemented a plan in collaboration
with the health services on the islands that every episode of self harm behaviour would be reviewed by the team. This often also resulted in telephone consultation
-3(-
with Darwin Urban Mental Health Services Remote team Psychiatry registrar, and pecasionally in transfer to Darwin.
1998 A two day “Exploring Together” workshop was conducted (funded by the YSPS} in collaboration with the Victorian Parenting Center. The aim was to enhance coping skills in children.
15, The general THS response to suicide Treatment
Dr Nagel advised that the suicide prevention strategies must be long term. The emphasis must be on life education programmes aimed at the school children, because when those chilcren leave school, they enter the highest risk group for acts of self-harm.
The treatment of those at risk of suicide needs to address a range of individual, family and social issues.
fa) The Individual
. Access to mental health services for assessment and treatment of associated mental ifness that is culturally appropriate.
a Substance use disorder treatment strategies.
!
(b} The Bereaved Support to those bereaved by suicide.
(c) Community and Whole of Population Approaches
e Reduce access to means. There is some evidence that the process of buying back firearms in the Territory may have diminished their use as a means of suicide.
The community strategy of restricting access to power poles in the Tiwi Islands is another example of such a strategy.
. dentify and promote goad media practice.
. Promote help-seeking among young people.
» School based and community based programs on emotional coping skills.
. mprove emergency responses,
» Support people at risk in the legal system.
e Promote models of suicide prevention: e.g. Yarrabah model.
¢ Promote social justice and reconciliation with Aboriginal people.
. Daia collection anc information sharing, identification of a ‘comonunity at risk’, The implementation of a unified computerised community information system in THS is an example of improved data collection.
Mental health services in the NT provide access to assessment and treatment and different levels of community based crisis response.
The process for referral to mental health service from any Aboriginal community is usually via the family, an Aboriginal Health Worker cr Mental Health worker or the community health nurse, GP or District Medicul Officer (DMO),
A24 hour telephone consultation service is available and assessnent at the hospital is also available all hours.
In the Darwin Urban region a 24 hour mental health service is available for crisis assessment. The availability of specialised mencal health staff on cammunifies is usually restricled lo an Aboriginal Mental Nealth Worker.
Local general practitioners or DMO’s are available for consultation affer hours either in person or by phone or via emergency evacuation.
Pollow up to the community is available by limited outreach from the in :patient unit and through liaison with local mental health services.
Mentai health services also share responsibility to offer:
*« Life promotion
® Ongoing treatment of mental illness
. Education and training « Acvocacy
Specific services in the above areas through THIS are:
« Life Promotion Officers - presently corsulting widely, nehworking with relevant community groups, collecting resources, and developing education packages. (Sco Attachment A of the statement of Dr Nagel).
Provision of ongoing treatment of mental illness in Darwin or by telephone consultation, via regular visits to remote areas through specialist outreach, and through video and teleconferencing.
Education and training to some relevant groups and advocacy in individual cases ig available.
Aboriginal Mental Health Services
There have been major changes in the model of service delivery to Aboriginal people in recent years in the NT. THS impiemented a fwo year project involving consultation with Territory Aboriginal People, which resulted in Guidelines for Aboriginal Mental Health:
. Trauma and loss related to colonisation must be addressed in terms of prevention and healing.
e The centrality of family and kinship must be recognized.
« There is no single Aboriginal culture or group.
Darwin Rural Mental Health Services
The Darwin Rural Mental Health Program commenced in 1988 and in 1998 there were five Aboriginal Mental Health Worker positions located in the Darwin Rural district. : :
of
Adl Aboriginal Mental Health Workers have access to the formal training provided by Batchelor College, and other tertiary institutions. The Batchelor course commenced in 1996 and allows the Aboriginal Mental I[ealth Worker to gain a recognized certificate.
THS also has Aboriginal mental health worker positions in Last Armhem District, Katherine, anc. Atice Springs.
In September 1997, the Mental Health Services Team at Darwin Rural won a gold medal for innovative health promotion in Aboriginal Mental Health and a silver medal for team work at the Australian and New Zealand Mental Health Services Conference.
Inpatient Services
Darwin Urban Mental Health Services provides inpatient treatment to the Northern Region of the Territory. Following an evaluation in 1995, and as a result of the Aboriginal Heatth and Mental Health guidelines developed by THS a number of changes ta service delivery were made:
« Liaison with Darwin Rural Mental Health and employment of two Aboriginal Mental Health Workers as a joint appomtment to beth Darwin Urkan and Darwin Rural Menial [ealth Services
® <A training position for psychiatry registrar in indigenous mental health.
Training of all new staff in cultural awareness.
Ullization of videw conference and teleconference to link regularly with remote areas.
The specific links with the Tiwi island community are via community follow up visits from the AMHW’s, access to telephone advice and specialist assessment in Darwin either as an inpaticnt or an outpatiert.
Two further Abcriginal Mental Health Worker positions commenced in 1999 based in the Darwin Urban Mental Health Services Corrmunity Centre.
The transition of health service provision to the Tiwi Health Board from the Darwin Rural Mental Health Team commenced in 1998, and staff and organisational changes, have altered the nature of these relationships im the short term, howeve: there remains a sound basis for ifaison from inpatient to community services.
Aboriginal Family Violence Stratezv
AFVS Project Officers working in partnership with a number of cummunities including the Nguin community have developed a community action plan which takes a long lerm strategic approach to eliminating farrily violence.
Primary Health Care - Rural
The provision of health centres, resident nurses, resident AMHW’s, routine DMO visits, 24 hour emergency consultation, retrieval, medical evacuations. [Patient Assistance Transfer Scheme (PATS) assists access to specialist treatment. Health centres offer after hours catl out.
Coordinated Care Trials
Three key streteyies of these trials (one on the Tiwi Islands and one for Katherine West remote communities) are to develop a flexible funding pool, standard care plans for the whole population, and community control achieved by local heaith boards controlling the funding pool and purchasing services on behalf of clients (hence the commencement of the Tiwi Health Board).
Aboriginal Employment
A plan which addresses some of the ctltural and structural berriers to the employment and advancement of carget groups wich include Aboriginal people.
Aboriginal Health Workers
The Aboriginal Health Worker Program commenced in 1076. Aboriginal Health Workers undertake formal post secondary and tertiary training. The NT was the first to register Aboriginal Health Werkers through the NT AHW Registration Board in 1985.
Aboriginal Living with Alcohol Program
The Aboriginel Living with Aleohol Program responds to an individual community following invitation. Information about alcohel is shared using both visual anc story telling processes.
Aboriginal Cultural Awareness Program
Four levels of training were developed through Territory wide consultation and are provided in order to cater for siaff with different levels of contact with or influence over Aboriginal services.
Suicide Prevention 18 a key feature of the following Comirconwealth strategies: the First ard Second National Mental Hea'th Strategies; fhe National Corisultaficy report on Aboriginal and Torres Strait Islander Mental Health (1995}; the ‘Mental Health Prevention and Promotion National Action Plan (1999); the National Youth Suicide Prevention Strategy (1995); and the National Suicide Action Plan (Draft - 1999}, The Royal Commission into Aberiginal Deaths in Custody and the Stolen Generation proceedings have alsn heen important milestones in the development of a nalional response to suicide.
The Northern Territory Government is developing a Youth Suicide Prevention Stratecy which will be consistent with the national strategy but with a special relevance to the NT. The Northern Territary’s action was in response to a perceived high incidence of suicide attempts in the Territory. In setting up a comumittee to develop the strategy, the Government expects a draft strategy by early 2000,
The Permanent Inter-Departmental Committee to Develop a Youth Suicide Prevention Strategy has examined policies from other States and the ACT to address youth at risk, early intervention strategies and support for families and communities. The Suicide Prevention Strategies adopted by Western Australia, Tasmania, Queensland, Austratian Capitat Territory and New South Wales have been terncderecl.
The Commit-ce has alse identified those resources that are currently available in the community and how they are addressing aspects of suicide and in particular youth suicide.
Mr Jones, Counsel for the families, asked Mr Martin why there were no community representatives on fhe Committee. Mr Martin advised that a primary task of the members, comptiying Northern Territory Government people, together with a Commonwealih representative, is to identify and invelve community groups in developing the strategy. The Committee met with interest groups in Alice Springs and Darwin in September and October 1999 for that reason.
oo
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Copies of the minutes of the meetings of the Committee have been fendered.
1?. Future Directions for Strategies for Suicide Prevention in the Territory
. Support and monitor the Lie Promotion Officer Project on Tiwi and other Aboriginal communities
. Utilise the fincings of the National Stocktake in order to adapt effective interventions reported.
Continue to develop a suicide prevention strategy, through the Project Officer, Dr Bauert, addressing allage groups and utilizing the information gained from the above two projects with clear objectives, strategies and performance indicators.
Continue to develop the five year mental health plan that addresses the key issues of the Second National Mental Health Plan and inclucles mental health prevention and promotion and a facus on youth, the aged population’ and the Tadigenous population.
Monitor and support the Aboriginal Coordinatec Care trials, particularly the suicide prevention projects on the Tiwi Islands
Dr Parker reports the clustering of suicides in the Tiwi community suggests a community at risk. The risk is heightened by community grief, the apparent normalization of suicidal behavior, and role modeling of the behavior of those people who have committed suicide.
With the two very recent further deaths, the Neuiu community will need positive support ta persevere with its current programmes for suicide prevention.
The Tiwi Health Board will need particular assistance at the community and Government level. Where the focal community assumes responsibility for health care, the whole community must become involved and not leave the task to a few overworked individuals.
Such an in-depth ing uedt ab about suicide, with the attendant publicity that it attracted, has always cartied the; risk that it may lead to an exacerbation of the problem of suicide and attempted. This leads to the seeming contradiction that it is important that the extent of the problem be publicly known so that effective responses can be made, On the other hand, the publicizing of individual suicides causes particular difficulties to the family and the community. The mecia is reminded of the media pacs prepared for the reporting of suicides.
A positive outcome of fais inquest would be the development of successful strategies for suicide prevention on the Tiwi Islands. This is only likely to be achieved through the Nguiu community in particular and the Northern Territory in general, openly acknowledging the extent and nature of the problem of suicide and self harm and having the will to respond.
David Parguhar
Counsel for the Northern ‘lerritory
nF
IN THE MATTERS OF Inquest into the deaths of GARY PETER TIPUNGWUTI
I. These submissions are made by Counsel assisting the Coroner in the Inquest into the deaths of Gary Peter Tipungwuti, Patrick Raymond.
Kerinaiua, Noeline Puantulura & John Gerard Orsto heard before the Cotoner Mr G Cavanagh SM on Monday 16 August 1999, Thursday 19
’ August and 10 November 1999. In continuing deference to cultural sensitivity and custom, the four deceased persons are not identified by flame.
« The Coroner’s jurisdiction in this matter;
® How ibis inquesi came into being:
e Abriefsummary of the circumstances surrounding the deaths;
® The investigation;
4, Further, the Coroner may direct that more than one death be investigated at the one inquest pursuant to section -14(4) of the Act.
6, On 13 October 1998, Superintendent Warren O'Meara wrete to the Coroner’s Constable drawing attention to two of the deaths. Inter alia, Superintendent O'Meara said in his memorandum:
“It would be fair to say that the deaths have shocked the COMMuFIty and lead to a great deal of unease over the escalating prevalence of such occurrences... Lam led to believe that there is on average, 2 to 3 attempted suicides a week which have been termed ‘attention seeking’. This iz a problem that appears unique to the Tiwi Islands and needs to be examined. An inquest into this matter may be an opportunity to bring these problems out into the upen and find solutions before further untimely deaths occur.”
The full terms of Superintendent O’Meara’s letter are set out in Exhibit “1” in the proceedings.
communication.
this inquest.
should be commended for the initiative which gave rise to this ina uest
and fhe concern expressed for public health and safety issues.
The first deceased
e The first deceased was the youngest of five children born to Mr Michacl Daniel Tipungwuti and Mrs Marina Agatha Tipungwuli.
He was 18 years of age at the time of his death. At around 0230
hours on Friday 21" August 1998, the deceased was found by his father at their residence, hanging from a length of nylon rope tied to a verandah roof rafter.
Members of his family had obviously thought very hard about the first deceased’s death. It was very clear that the first deceased’s family loved hin and was still grieving his loss.
They could only suggest that the first deceased had become depressed because sufficient money to send him back to Croker - Island for Ceremonies could not be raised. From the evidence taken on Bathurst Island, it appears that there may have been some fear on the part of the deceased that if he did not return to . Croker Island to take part in the Ceremonies then dire conscquences, cven death, would result. This would provide a culturally based reason why the deceased may have sought to.
take his own lite instead.
The frst deceased had apparently attempted to hang himself the day before because he believed no-one was helping him get ta the Ceremonies. His brother, Sylverius had told him not to try to kill himself again. The deceased had also told his mother that if he didn’t get the money then ‘something would happen’. In response to this, the deceased’s mother tried to obtain sufficient money for he deceased to make the journey. However, on the short notice the deceased gave, her best efforts raised only $120.
The deccased’s brother asked the deceased to give the family a couple of days to raise the money he said he needed.
The Toxicology Report indicated that the deceased had a nil blood alcchol concentration and there was no evidence of the presence of drugs af abuse, including cannabmoids. (See Exhibit 2, Tab 1 1). The first deceased was, however, a known consumer of marijuana. Despite the Toxicolagy report, Dr Parker thought
that the anxiety exhibited by the first deceased could be duc to a marijuana induced psychasis.
The second deceased
e At around 2320 hours on Friday the 21 of August [998, Ms Tipungwuti found the deceased hanging from an clectric extension cord which was Lied to a ceiling fan in the bedroom.
« The deceased and Ms Tipungynuti had left the Nguiu Social Club at about 7.00pm that night. Ms Tipungwuti says thal she and the deceased had an argument when they were walking home and he punched her on the lip. It would appear that both were intoxicated. Upon returning home, the deceased tried to hang himself. Ms Tipungwuti intervened and he assaulted her again.
She then left the house and when she returned she found that he had hanged himself and was dead.
« Ithas been suggested that the deceased felt guilty because he had assaulted his defacta. It has also been suggested that the deceased was aware of the fact that his next daar neighbour, the first deceased, had suicided that morning and this may have affecled him,
« Itis noted that Ms Tipungwuti stated that the deceased had tried to commit suicide about a year and a half prior to his death. On that occasion, the deceased had tried to hang himself from a tree
near the cemetery. At that time Ms Tipungwuti was able to cut him down with a knife before he harmed himself.
® The Toxicology Report indicated that the alcoho! concentration im the deceased’s blood was 197mg/100ml. No evidence of drugs of abuse was detected in the deceased's blood. (See Exhibit 2, Tab 24)
The third deceased
¢ The third deceased was born on Bathurst Island on the 2™ of March 1976 and was aged 22 when she died. She was the fitth of eight children born to Mr Noel Ampurrindiindi Puantulura and Mrs Franciose Puantulura (deceased). Ms Puantulura was unmarried and had a seven year old daughter.
© On 28 October 1998, at about 10.00pm Ms Puantulura climbed to the top of a power pole in the community, threatening to kill , herself. She then fell from a height of approximately six metres from the top of the pole, suffering injuries. Death occurred as a result of these injuries. Earlier in the evening she had consumed alcohol at the Nguiu Social Club.
e The deceased’s father, Mr Noel Puantulura, says that the deceased was upset because she had had a fight with her boyfriend that night. The deceased told her father that her boyfriend was going to leave her and she was going to kill herself. The deceased’s family tried te reason with her but the deceased refused to listen and ran out of the house and to a power pole situated near a roundabout at the Jubilee Park. The
deceased then climbed the pole.
« The deceased’s family pursued her, telling her ta come back.
Family members and a number of other people gathered at the base of the pole. Various people tried to climb the pole but were unable te reach the deceased. Her family tried to talk the deceased into coming down from the pole. There is some evidence to suggest that the deceased fel] asleep whilst up the pole and, as a result, fell off. A number of people state that the deceased became silent for some time before she fell from the pole. (See Exhibit 2, Tabs 29, 30, 32}
The fourth deceased
« The fourth deceased was born on Bathurst Island on the 4thef February 1946 and was 32 years of age at the time of his death.
The deceased was married and had three children, but had separated from his wife in about 1992. The deceased's estranged wife and their children lived at Rangku. He did not have custody of the children.
« Ataround 11.30pm on Monday the 30" of November 1998, the deceased was found by friends at his brother’s residence, hanging irom a length of rope tied to verandah rafter. The rope was some length and so he was able to kneel/sit on the verandah and
slump forward.
® On the night of his death, the deceased had worked as a bouncer at the Nguiu Social Club. When the Club closed at about 7.00pm, the deceased and some of the staff stayed on for drinks.
The deceased left the club at about 9.00pm with Mr Simon
Tipungwuti and another person. The deceased was then dropped off at the house where he was staying.
At about 11.15pm, Mr Simon Tipungwuti was awoken by the deceased, who said he wanted to talk to him. Mr Tipungwuti told the deceased that he was too tired to talk and that he wanted to sleep. The deceased apreed io this and then left.
Mr Tipungwuti did not notice anything unusual in the conduct or the demeanor of the deceased, When the deceased left, Mr Tipungwuti went back to sleep. The deceased then went to his brother’s house. However his brother, Mr Alec Orsto, was asleep ‘ and did nol talk to him. The deceased then went to the verandah of the house, where he hanged himself.
The deceased’s brothers believe that the deceased was upset because he missed his chitdren and he was not able to see them often because they live at Rangku.
The medical records from the Nguiu Health Clinic indicate that the deceased had previously attended the Clinic on 15 January 1990 with a self-inflicted shotgun injury to his right upper arm.
He told the doctor that he was having problems at home with his wife. (See Exhibit 2, Tab 47 or original record in Exhibit 5}
The Toxicology Report indicated that the alcohal concentration in the deceascd’s blood was 199mg/100ml. No evidence of drugs of abuse was detected in the deceased’s blood sample. (See Exhibit 2, Tab 50)
11.1 submit that the Coroner should make the following findings pursuant to section 34(1)(a) ofthe Act:
e The ‘first deceased’;
The identity of the ‘first deceased’ was Gary Peter Tipungwuti; The time and place of death was approximately 0200 hours on 21 August 1998 at his parents’ residence at Nguiu, Bathurst Island: see Investigating Officer’s report to Coroner in Exhibit 2, tab 2; ‘ The cause of death was hanging: see Pathologist’s Report of Dr TJ Sinton, Exhibit 2, tab 9.
® The ‘second deceased’;
. The identity of the ‘second deceased* was Patrick Raymond Kerinaiua: The time and place of death was approximately 2330 hours on 21 August 1998 at a residence in Nzuiu, Bathurst Island: see Investigating Officer’s report to Coroner in Exhibit 2, tab 13; The cause of death was hanging: scc Pathologist’s Report of Dx T J Sinton in Exhibit 2, tab 22.
« The ‘third deceased’;
The identity of the “third deceased’ was Noeline Puantulura;
The time and place of death was approximately 2030 hours on 28 October 1998 in Nguiu, Bathurst Island: see Investigating Officer’s report to Coroner in Exhibit 2, tab 25;
The cause of death was multiple injuries as a result ofa fall from a height: see Pathologist’s Report of Dr T J Sinton in Exhibit 2, tab 35.
« The ‘fourth deceased’;
The identity of the ‘fourth deceased’ was John Gerard Orsto;
The time and place of death was approximately 2315 hours at a residence in Nguiu, Bathurst Island: see Investigating Officer's report to Coroner in Exhibit 2, tab 38;
The cause of death was hanging: see Pathologist’s Report of Dr T J Sinton in Exhibit 2, tab 48.
12.Lsubmit that the Coroner should find that of the four deaths, which occurred in Neuiu in 1998, three were suicides by hanging and one was
a death by misadventure and/or accident..
13.[t is submitted that the Coroner should find that the death of the third deceased was by misadventure or accident, rather than suicide, The
evidence presented to the inquest in regard to the third deceased suggests she may have fallen asleep, causing her to fall from the power pole or, alternatively, she may have simply fallen accidentally from the
pole due to her state of intoxication.
14.Gtven this evidence, I submit that the relevant standard of proof is unable to be met in regard to determining that this death was a suicide rather than accidental, Suicide should never be presumed and, indeed, the presumption should be against suicide, This prestmption against suicide has been supported by case law. There is cogent evidence that the other three deaths, the subject of this inquest, were suicides.
15.The investigation by Senior Constable Anne Lade was thorough, professional and objective. -It is clear that she interviewed many persons and their statements have provided a valuable factual base upon which the inquest could proceed. The early insights of Senior Constable Lade have been confirmed in large part by the evidence.
16.1 submit that the Coroner should comment favourably ou the quality of the investigation.
17.The Coroner has the discretion to comment on matters including public health or safety or the administration of justice connected with the death under section 32(2) of the Aci, or to report to and make recommendations to the Attorney-General under sections 26(2) and 35 of the Act.
18.It is appropriate to deal first with the issue of whether the Coroner should make a report under section 35(3) of the Act to the Commissioner of Police and the Director of Public Prosecutions, It is submitted that there are no circumstances which eould induce a belief
in the Coroner that any crime has been committed in connection with any of the four deaths under inquiry and that the Coroner should not make any report to the Commissioner or the Director as set out in the sub-section. ‘The requisite standard set out in cases such as R v Taktak (1988) 14 NS WLR 226 has simply not been made out. No question of any crimina! conduct arises,
19.In respect of your power under section 32(2) of the Act to comment about a matter including public health or safety connected with the death, evidence has been given during this inquest in respect of a number of issues which call for comment, There ig also a proper basis for you to make recommendations to the Attorney-General.
20.l€ is appropriate at the oulset to provide an overview relevant to public health and safety. It is submitted that the circumstances swrounding the four deaths indicate very serious public health and safety issues.
21.At the outset it must be said that the public health and safety issues thrown up by this inquest are truly tragic in their proportion and have an urgency which the communities on the Tiwi Islands, the Tiwi Health Board, Government and Government Agencies cannot ignore,
23.The evidence in this inquest pointed to very serious underlying problems on the Tiwi Islands, which impact upon public health, The underlying problems need to be considered and proactive measures ~ need to be taken as a matter of urgency. The underlying problems identified in this inquest are:
(a) Alcohol abuse across the community;
(b) Marijuana abuse;
(c) Violence, especially domestic violence: (d)Family breakdown;
(e) A weakening of the traditional and cultural values in modern Australian society;
(£} Lack of employment, opportunity and other advantages enjoyed by many in non-Aboriginal Australia; :
(g)A clash of culture, occasioned by various means, which can lead to a sense of hopelessness and low self-esteem, especially among
young men; and
(h) An epidemic of attempted suicides or apparent aitempis at suicide or self-harm, and imitation of suicidal behaviour. On this point, colloquially speaking, some witnesses used the expression “copy eat syndrome”. I do not choose to use this expression in these submissions as it trivialises what is clearly a tragic and very complex issue (see ‘Royal Commission Into Aboriginal Deaths in Custody’ National Report, Volume 2, page 124, paragraph 11.11.54).
24.There were a number of matters given in evidence in this Inquest which touched directly upon public safety issues. These were:
(a) Domestic violence and the danger to the safety of women and children and
(b)the tragic phenomena of using power poles to climb and then attempt suicide by electrocution, or the use of the poles ina reckless manner to attract attention and which could lead to death by misadventure.
26.The Power and Water Authority (PA WA) has been pro-active and installed guards on its power poles at Nguiu. Unfortunately, a number of witnesses attested that one type of guard installed by PAWA has not been successful in preventing juvenites and other pcrsons from climbing the poles. The type of guard in question is the spiked variety of pole guard which was seen on inspection in Nguiu. Mr Birk, the manager Rural Services North, has called these guards the ‘crown of thom devices’. There is no evidence in this inquest that any person had circumvented the wired guard. The evidence did not canvass the installation of guards at any other Tiwi community. The submissions, however, made in respect of Nguiu apply to other communities where guards have been installed.
27.11 is submitted that no criticism should be made in respect of PAWA's choice of guards, as they were obviously intended to stop people from climbing further up PAWA poles. However, the ‘crown of thorn device’ instatled by PAWA has been shown to not have achieved what was intended. There is a need for these guards to be replaced. PAWA
is alerted by these proceedings that the corrective measures put in place have not achieved the intended goal.
with police and the Nguiu Council, and any other relevant body,
regarding the effectiveness of the guards on the poles on the Tiwi
Islands.
29.1t is submitted that the Coroner should recommend PAWA remove the
spiked guards installed and replace them with ouards which prevent people from climbing the poles.
30.It is clear that domestic violence on the Tiwi Islands is at a totally unacceptable level and. operates in the context of family breakdown on the Tiwi Islands, frustration, suppressed anger, hopelessness and the
abuse of alcohol! and marijuana.
31.The evidence of Sergeant Peter Cumming is compelling. Nearly all police work on the Tiwi Islands is attending to disturbances which are alcohol related. Sergeant Cumming went so far as to swear that 98% of police work was alcohol related in some way. Indeed, in answer to a question from the Coroner, Sergeant Cumming agreed that if you removed the licensed outlets there would be very little justification for mauch of the police presence on the Tiwi Islands.
32.Nearly a!] witnesses who reflected upon the phenomenon of suicide in Tiwi society and the spate of attempts and imitated behayiour, identified domestic violence as a major underlying problem. They related it closely to alcohol abuse. It is clear that domestic violence is at an unacceptable level and pro-active and urgent intervention is _ required in the interests of family life, wives, mothers, women and
am 16
children. The identified period when most of the damestis violence at Neguiu oceurs is after the social club clases.
acquire living skills, is readily apparent.
35.Women and children need a means whereby they can, at least temporarily, escape domestic violence, achieve some respite from it and help to control it.
36.Failure to address these problems can be damaging to Tiwi society across generations. You will recall your meeting with the Tiwi children who responded so positively to the invitation to speak to you.
‘They referred to the problems of aiccho] abuse at home after adults retumed to their often crowded houses from the social club. What pictures of domestic violence had they seen that fed to these comments? What breakdown had they experienced with intoxicated
relatives?
37,.Dr Parker in his very heipful report identifies, inter alia, confusion in a child’s role within the family and problematic communication within the family as being positively associated with later suicidal thinking.
Such confusion can only be magnified in a home where therc is violence and poor parenting. See page 9 of Dr Parker’s report,“ An Audit of Coronial Records for the ‘Top End’ of the Northern Territory
comparing factors in Aboriginal Suicide apainst other suicides in the
Region.’”
Islands and subjected those years to critical professional analysis. He agreed with the research work of Earnest Hunter in the Kimberlys that predisposition or increased risk of suicide is created in an individual’s childhood experiences. He attested to the absence of suicide in the community when he was there twenty years ago, but that it had developed after over twenty years of expasure to alcohol availability and alcohol related domestic violence.
39.Dr Parker referred to the ‘twenty ycar gap effect’. This reference was
to the generational impact of childhood exposure to domestic violence and alcohol abuse. He witnessed such alcohol related violence twenty years ago. The children who were exposed to such violence are now the young generation exhibiting such alarming propensity for suicide and self-harm.
40.Dr Parker referred to short and long term strategies to deal with such
destructive behaviour (strategies which Mr William Barclay on behalf of the Tiwi Health Board agreed with expressly}. These strategies concemed steruming the availability and quantity of alcohol, provision of health worker Intervention to deal with ‘at risk’ persons, a domestic violence unit and long term educational initiatives to assist young Tiwi persons, especially boys, to deal with their feelings.
41.Mr John Maher, an experienced psychiatric nurse, alsa identified
violence, particularly domestic violence and abuse, as a continuing and common factor in the attempted suicides he investigated with Pius
Tipungwuti. |
~ , 18
42 Tt is submitted that the Coroner should recommend the creation of a domestic violence unit on the Tiwi Islands which can develop practical strategies and provide respite and care for victims,
can temporarily house victims of domestic violence.
curriculum programmes which allow young Tiwi people to discuss and deal with feelings and experiences which might increase their risk for
suicide in later life.
45.It is submitted that the Coroner should recommend that a copy of the
transcript of 10 November 1999 be referred to the Department of Education and the Catholic Education Office.
46.An overview of the evidence presented to you shows a society which has struggled with the problem of suicide and an epidemic of aitempted suicide or attention seeking threatened or suicide attempts. The Tiwis haye made, and continue to make, concerted efforts ta deal with the tragic complex issues associated with members who chose death over
life, or who appear to chose death over life.
47.It is important that the genuine cooperation you have received from the Neuiu Council, the Tiwi Health Board, family members and concerned.
Tiwis be acknowledged. This coronial inquest has had genuine cooperation from the Tiwi people. With great courage they have bared their society and stated that despite their good efforts, they do need
help. The Tiwis have adapted a number of programmes tc deal with suicide prevention. They have demonstrated their hard work to date, They have also acknowledged their helplessness 10 combat the debilitating and corrupting influence of alcohol.
complex problems.
30.This aspect of encouragement to persevere is particularly important.
Sinve the inquest adjourned, there have been two more deaths, yet to be investigated fully, but which have compounded the concerns and shock felt by the community arising out of the four deaths the subject af this inquest. Concer appears to have risen to the point of despair and good willed, caring people are, to paraphrase Mr Barclay’s expression - ‘despairing’. There is no doubt Tiwi people sce themselves as fucing a crisis and, for the first time, doubt appears to have arisen about whether this crisis can be overcome. There is a need that the Tiwi Health Board and Tiwi people be reassured that they are not alone and that their problem is also the Northern Territory’s and Australia’s problem.
51..would submit by way of initial comment that you acknowledge the constructive work the Tiwi people have done so far to address the tragic problem of suicide im their community. I would also submit that
before you adjourn to consider your inquest findings, and any comments and recommendations, you encourage the ‘Tiwi people to persevere and remind them that they are not alone and assistance in examining the problem and dealing with underlying issues should be forthcoming.
invelved in this inquest calls for an all of Gavernment approach to help alleviate the tragic underlying causes and prablemis.
on,
53.Statistics gathered by Dr Chris Harrison, who gave evidence at the , inquest, indicate that since 1991, there have been eight deaths by suicide on Bathurst Island, including the four deaths the subject of this inquest. Since Dr Harrison gave his evidence, there have been two more deaths which are alleged to be suicides. If the Coroner accepts my submission that one of those deaths the subject of the inquest, being that of the third deceased, was accidental, then the number of
; deaths by suicide on the Tiwi Islands up to the time of the inquest will Le be reduced to seven. The two further deaths since the adjournment of this inquest have also impacted and give an urgency to this inquest.
54.Noihing detracts from the fact thal between the period of 21/8/98 to 34/11/98, there were four tragic deaths on Bathurst Island. There is also evidence of an alarming number of apparent atternpted suicides and incidents of self-harm (see Exhibit 2, Tab 59). So much so, that it is fair to describe the attempts at suicide in Tiwi society as an epidemic.
55.Ms Sheridan O*Leary said in her statement (see Exhibit 15):
“Tt seems as if there is an epidemic of depression among the Tiwi young people that seen to run a rapid and uninterrupted course to the
tragic violent loss of life. ”
56.Dr Harrison stated that he had commenced to gather statistics in respect
of suicides, attempted suicides and incidents of self-harm at the beginning of 1997. It is noted from his statistics that, at the time he gave his evidence, there had not been a successful suicide on Bathurst Island since that of the fourth deceased, up to 23/6/99, There had, however, been over 30 attempts, expressions of suicidal behaviour or self-harm incidents reported by Dr Harrison. From a different perspective, Sergeant Cumming attested to fifty police call outs to attempted suicides since he had arrived on the Tiwi Islands in September last year. He desoribed these fifty call outs as only the ‘tip of the iceberg’.
harm are very difficult to determine. However, Dr Harrison gave evidence that he has noticed patterns of behaviour which indicate that there are contributory factors. He stated that one of the most obvious is the involvement of marijuana and/or alcohol which acted as ‘triggers’.
Another factor, especially with females, is incidents of domestic violence, and the other issue is mental health problems such as depression or drug relaied psychosis. Dr Harrison agreed that the issues of self-esteem and cultural crisis were also relevant factors.
58.Dr Harrison believed that people wanting money or something else
from their family also often use the threat of suicide as ‘bribery’ or a “blackmail tovl’. Such threats can also be an attention getting device or a cry for help, expecialiy if there is trouble within personal relationships. Dr Harrison was also concerned about imitated suicide behaviour, that is where people are influenced to attempt suicide or
self-harm after being exposed to the same behaviour in other people.
Dr Parker shared this concern as did Brevet Sergeant Cumming.
He was joined by Dr Parker, Ms O’Leary, Superintendent O’Meara, the psychiatric nurse John Maher, the Tiwi Health Board Executive Director Mr Barclay and Ms D. D Luta, the life counsellor. A chorus of witnesses have evidence all one way in this inquest — alcohol and marijuana abuse is out of control, is destroying family life, poisoning efforts to try to address the problem and debilitating society to the point that suicide is an option readily taken.
60.It is clear on the evidence that alcohol abuse in turn gives rise to domestic violence and the quality of family life for the women and ‘ children is destroyed.
61.Dr Tricia Nagel gave evidence that the national suicide rate is 13.1 per 100,000 (ABS 1999). However the NT rate for 1997 is much higher being 34.8 per 100,00 population. She suggested that the reasons for the disparity were that NT has a majority of rural areas (and it has been noted that suicides in the rural area have increased in recent years), the isolation experienced in the NT and the fact that NT has a high Aboriginal population. (See Exhibit 7)
62.Dr Nagel suggested that the risk factors for suicide might be categorised into biological, psychological and social background factors. These included factors such as menial illness including depression and psychosis (biological), stress, despair, ‘copycat’ behaviour, social isolation and loss of role models for dealing with stress (psychological), unemployment, poor housing and socioeconomic disadvantage (social). Dr Parker also canvassed the
general risk factors in the population and the specific risk factors in the Tiwi population.
63.Dr Nagel gave evidence of general contributing factors relating to suicide. She indicated that the specific contributing factors to Aboriginal suicide are many and varied. She nominated spectfie factors which were cultural change, which resulted in a high incidence of violence, unemployment, overcrowded housing, substance use and poor access to services, identification with the victim, through media coverage or proximity to the house where an individual suicided, and cultural meanings of hanging, resulting from a media-driven stereo type and which may be linked through ‘place meaning’ with the site of a hanging.
64, Mr John Maher cautioned that while it was very easy to be simplistic about the likely causes of self-harm, the continuing and common
factors he observed were:
(a) Violence, particularly domestic violence and abuse;
(b) Alcohol abuse across the whole community affecting the mental health of all;
{c} Cannabis abuse; and
(d}.A cultural clash between the collectivist philosophy and the individual philosophy.
Alcohol
65.As already noted, there is no doubt on the evidence that alcohol abuse is seen as 4 major, ifnot the primary underlying problem which is associated with the patterns of suicide and attempted suicide. There is also ne doubt that something needs to be done to address alcohol abuse and resultant social problems on the Tiwi Islands. Action, tirgent
action, needs to be taken te reduce the level of consumption of alcohol
on the Tiwi Islands.
66.In three of the four deaths the subject of this inquest, alcohol was a factor. In evidence, Dr Nagel, Dr Parker and Dr Harrison agreed that alcohol and marijuana, and the combination of the two, can act as a ‘trigger’ or produce a psychosis which could contribute to incidents of suicidal behaviour. Further, Dr Harrison’s statistics reflect the fact that alcohol featured in many of the attempted suicides or self harm behaviour he had noted. Alcohol was identified by Mr Barry Purantatameri and Mr Barclay as the main underlying problem in
suicide and suicide related behaviour.
67.Dr Parker stated that, during his time on the Tiwi Islands, nearly all of the deaths, accidental or otherwise, were related to alcohol. ‘
68.0n 19 November 1999, the evidence of Dr Parker, Mr Barclay, Sergeant Cumming and Barry Purantatameri indicated strongly that the main contributing factor on the Tiwi islands was alcohol abuse. Mr Barclay when he was resworn attested in the strongest of terms that the reason why he had agreed to be recalled was because he considered that he had not emphasised sufficiently strongly the influence of alcohol as a contributing factor. He attested that alcohol consumption was ‘out of control’ and no attempts or strategies, or suicide prevention could succeed until community alcohol abuse was addressed. Dr Parker was quite firm that alcohol] abuse was not in itself'a sign of some deeper malaise. Rather, when alcoho! is absent, life on the Islands goes on much as before. This is a significant and informed observation.
69.Qn the evidence before you the main contributing factor asso¢iated with suicide, suicidal behaviour or attempted suicides and seli/-harm is alcohol abuse. The tecent further spate of attempted suicides and two further deaths including that of the senior Aboriginal health worker had
prompted both Mr Barclay and Mr Purantatameri to request help and leadership from both within and outside the Tiwi community.
71.In Nguiu, the only licensed premise from which people are able to obtain liquor is the sociaf clubhouse, commonly referred to as ‘the club’. The club is open six days a week, from 4pm until 7pm. No takeaway liquor is permitted, A ticketing system operates which permits people to buy alcohol to the value of the tickets. Take-away alechol is permitted from the Milikapiti social club. There is evidence of abuse of the take-away licence,
72.One of the concerns raised by the Council and other witnesses was that for the past two ycars, the club had operated during the period of ‘bush holiday’. Bush holiday is taken during the month of June and, traditionally, families leave the community and ‘go bush’ for a month.
However, evidence was provided by the police that whilst normally the majority of families go away for the period, this did not occur in 1997 & 1998. The police believe that this was because the club did not close over that period, .
73.A number of witnesses complained abaut the destruction to family life of the opening of the Club on ‘Bush holiday’. Efforts had been made to close the Club, to no avail, Alcohol appears to have an insidious capacity to destroy leadership and civic decision making to the point that people are unable te achieve what is best for the family over what suits the alcohol drinking members of the community.
75.Itis submitted that you should comment upon the urgent underlying problem of alcohot abuse in the Tiwi Islands and that it was a factor in three of the four deaths.
76.It is submitted that you should comment that alcohol abuse has a frequent association with suicidal attempts or attempts at self-harm.
Government.
78.It is further submitted that you should recommend to the Liquor
Commission that it review the health implications of the ammount of
alcohol consumed on the Tiwi Islands based on the ticketing system which operates for the sale of liquor at Neuiu.
79.1tis submitted that the Coroner recommend that the Liquor Commission consider whether it should take stcps to reduce the availability of liquor for take away on the Tiwi Islands,
obvious that urgent intervention is required.
81.It is submitted that you should send a copy of your findings to the Commissioner of the Liquor Commission together with all written
submissions made to you in this inquest,
82.1 do not urge any specific measures which are properly within the jurisdiction of the Liquor Commnussion. This is properly a matter for it to consider and to utilise the Statutory procedures under the Liquor Act
if it is so minded te do so, All of the matters in this inquest are likely ta be relevant to the Liquor Commission’s deliberations.
Marijuana
83.It is also clear that there is marijuana abuse of an unacceptahle proportion on the Islands which can, and has, led to psychotic episodes
and incidents.
84_Evidence was provided to the inquest by ACPOs who live in the
community and the police who visit regularly that there is a large amount of marijuana, commonly known as ‘gunga’ on the Islands. The
~ fact that it is widely available and used by many, if not most, of the younger membets of the community was an accepted fact and one - which was readily acknowledged by the school children with whom .
you spoke. The community representatives agreed that the problem seemed most apparent, although by no means zestricted, to the younger people in the community. It was also agreed that the eunga is being brought onto the Islands from outside, rather than being grown there, It has been suggested that children as young as ten years old are smoking gunga. Mr Purantatameri said he saw a juvenile crying on the ground wanting money so he could buy and smoke more gunga.
85.The police state that they are frustrated in locating the sourcefs) of the drug. It was noted that some Council members believed that the police were not doing enough to combat the problem. However, without community support in actually identifying the ‘traffickers’ and couriers, or the community providing police with leads, police arc fighting a losing battle. I submit that the statement made by Constable David Moore to the effect that assistance was needed from the Council given that the problem was not just a police problem but also one for
the community was reasonable.
86,It would appear that police have made efforts to search aircraft on the mainland which are bound for the Tiwi Islands.
87.Like alcoho! abuse, marijuana abuse is a phenomenon that Tiwi people are ultimately going to have to face as being destructive to their people.
Policing at Nguiu
it is noted that Constable Moore submitted that a permanent police presence at Nguiu would assist in policing the marijuana problem. He was joined in this view by Sergeant Cumming. Indeed Sergeant Cumming said that 50% of the disturbances and problems at Nguiu would be stopped if there was a permanent non-Tiwi police presence there.
Indeed, it is apparent that the unavailability of non-Abotiginal police officers for mest of the week at Nguiu is an issue about which many are concemed. Many people called for a permanent non-Aboriginal police presence at Nguiu to assist and support the ACPOs, who face cultural taboos which sometimes inhibit effective policing. Mr Barclay and Mr Puranatameri saw it as essential, However, Superintendent O’Mcara indicated that there was not a need for further police presence at Nguiu.
The full time presence of nen-Aboriginal police would assist in providing help to victims of domestic viclence, health workers and children in the community.
The population size of Nguiu, relative to Pirlangimpi, makes that the current location of the non-Aboriginal police curious, It is submitted that more effective policing would be achieved if there were permanent non-Aboriginal police at Nguiu,
~. 29
92.In the past, it has often been said that the Nguiu community was sufficiently law abiding as not to require such a measure, The insidious nature of the problems thrown up in this inquest does call for reflection by palice management as to whether police resources are better deployed by moving the aon-Aboriginal police at Pirlangimpi to Neuiu.
93,.Sergeant Cumming indicated that the issue of the lacation of the nonAboriginal police members on the Tiwi Islands was under review by police management. It is timely that such a review of the location is underway.
94.1 submit that you should comment upor the community dissatisfaction
with the location of non-Aboriginal police on the Tiwi Islands.
95.1 further submit that you recommend that the result of the police
management review and reconsideration of the location of nonAboriginal members be communicated to the Tiwi people at Neuin.
Domestic Violence
96.Domestic violence is associated with deterioration of farnily life and alcohol and marijuana abuse. It too is a problem that needs to be addressed as a matter of urgency. Domestic violence appears as a factor in three of the four deaths ander inquiry.
97.1 have already made a number af submissions as to what you may seck to recommend when you have considered all of the materials. It is apparent from the evidence, inter alia, of Sergeant Cumming, Ms O’Leary and Barry Purantatameri that domestic violence is related to alcohol and marijuana abuse. It appears essential that if domestic violence is to be addressed, the problems of alcoho! and marijuana
abuse need also to be addressed both by medium to long term strategies and by practical measures such as I have submitted above.
Other Factors
98, Other factors which members of the Council, the community, the police and medical personnel suggested as influencing suicidal behaviour were problems with self-esteem, a lack of knowledge about how to manage conflict and personal feelings, ‘cultural stress’, access to outside influences tending to break down/infiltrate traditional values (videos, television and media} and mental health problems which are not able to be addressed on the Island,
99.The youth of the Tiwi Islands appear to be caught in a conflict. The.
wider world through the media presents a world of excitement and opportunity. Yet, for cultural reasons, they are tied to their islands and relationships. The opportunities and lifestyle often projected on
‘television is not a reality on the Islands. There are too few jobs which offer employment advancement. Often young people live in overcrowded housing. Add alcohol abuse and domestic violence to this and the world of many young Tiwis is poisoned and can lead to a sense of hopelessness, depression and the embracing of the immediate agents for escape — alcchol and marijuana. Dr Parker emphasised that the main problems were anger and prief which had not been addressed.
This anger and unresolved grief often related back to domestic violence and neglect experienced as children.
iO. Another facior which concemed the community and the police was the emergence of people using threats of suicide as a means of blackmail and/or and attention seeking mechanism. A number of people expressed their belief that individuals were threatening suicide purely as a method to obtain money from their families. This money would oftea be used to then buy alcohol and/or marijuana. The use of death as a threat signifies how seriously distorted the perspective of _ many Tiwis has become. It needs to be addressed in the longer term through effective educational and Life strategies.
Sexual abuse
There is no evidence of any of the four deceased having been the victim of sexual abuse by any person.
‘The tnvestigation by Senior Constable Lade showed that none of the four persons were the victims of sexual abuse by any particular person.
None of the family members spaken ta by police or who pave evidence, alleged sexual assault as being a circumstance surrounding the death of any of the four deceased.
Notwithstanding publicity, advertisement, request or investigation, no person has produced any evidence of sexual abuse as being a causal
factor in these cases.
. Northern Territory,
THS contributes some $2,055,000 per annum to the Tiwi Health , Board’s flexible funding pool. This sum excludes THS budgets for Tiwi Aged & Disability and Family & Children’s Services. These services are still provided by THS on the Islands. THS also continues to previde money to support the Tiwi for Life program, emergency evacuation services, dental, allied health, visiting District Medical Officers and renal dialysis.
In addition, THS is working in accordance with the First National Suicide Strategy in conjunction with the Commonwealth. A National Action Plan for Suicide Prevention is being developed as part of this Strategy. A Life Promotion pilot project has been set up by THS using funds providing by the national initiative. The Life Promation Unit became operational in May 1999, The project consists of two teams, one based in Central Australia and the other in the Top End, Their role is to wotk with individual communities and assist them to implement strategies which address issues of youth suicide, This is not Tiwi Isiand specific. (See Exhibit 6)
a - 33
116, Also, the Northern Territory Government has set up an interdepartmental commitice to develop a Youth Suicide Prevention Strategy, which will be consistent with the national strategy referred to above, The Committee expects a draft NT strategy to be developed by early 2000.
[tis clear that THS has been concerned and supportive, It has taken a consultative and sensible approach to this inquest. However, it needs to provide urgent assistance to the Tiwi Heaith Board in respect of addressing alcohol abuse.
Itis submitted that the Coroner comment on the need for THS to assist the Tiwi Health Board during this current difficult phase and to
‘provide support in developing effective community health and suicide -
prevention strategies and programmes.
Mr Barclay, the Chief Executive Officer of the Tiwi Health Board (THB), advised that the Board was set up in 1997 by the NT Government and was incorporated into the Commonwealth ‘Coordinated Care Trials’. THB receives funding from both the THS and the Commonwealth (through the MBS payouts) with the money being placed in a flexible funding pool. This allows THB to aliocate money in the manner in which it believes necessary, rather than having to deal with a set budget for particular areas. (see Exhibit 2, Tab 56}
THB has now taken over the management of the majority of primary health care services for the Tiwi Islands. The Board has managed the Nguiu health centre since April 1998, it has also manayed the Rangku out-station visiting service since that time. More recently, in April 1999, THB has taken over the management of the Milikapiti and Pirliangimpi Community Health Centres. THB currently employs 2 doctors, 8 health workers and 4 nurses engaged full time on the Islands.
THB’s senior health worker tragically died last week in circumstances relevant to this inquest.
"adolescent psychologist from Sydney, conducted a further series of .
workshops. A series of life promotion and suicide risk awareness workshops were then conducted by the menta! health team in collaboration with Gibson Farmer targeting the Men’s Drap in Centre,
councils and schools.
the Bathurst Island Youth Conference. This conference was facilitated by two young people from the Community in collaboration with.Mental Health FYCS and FACS staff. Up to 127 young people attended with representatives from council, police, school, the culture group, CDEP and the Community Health Centre.
The Bathurst Island Men’s Conference. This was run by ihe council and THB.
« An ‘Exploring Together’ workshop was conducted in collaboration with the Victorian Parenting Centre which aimed to enhance coping
skills in children.
Before this, Charles Stuart University through the Commonwealth had provided some funding, and Mr Gibson Farmer was employed as part of a national suicide prevention project. The Board however was not specifically invelved in this project, The current project employs one full time Life Promotion Officers, Ms Dee Dee Luta, and Mr Gibson Farmer, a3 a part time worker. It is intended the project will build dn the earlier workshops and held its own workshop in April 1999, dealing
with issues regarding suicide.
119, A positive initiative and one which appears to have tangible and practical results is the youth, sport and recreation facility at Ngutu. The .
facility appeared to be well equipped and well run and was popular with young people.
to socialise.
recreation in terms of personnel, facilities and infrastructure. A great
deal of effort was put into the cleaning of the shed allocated for the project and turning it into a multi sports factlity.
The facility is used by school groups each school day during school hours. It is also used by the general community for movies, gospel groups and communily events. Between 1.30pm and 8pm each day between 200 and 300 people use the building and its facilities. Given the size of the Nguiu population, this is a significant number who use the sport and recreation facility.
The facility allows people to come and gather and play sport. It provides a healthy alternative to youth gathering around the streets and, no doubt, a respite from home when drunken family members return from the club, The facility is used for more than just sporting activities. ” Mr O'Sullivan refers to the use of the facility for barbeques and all the healthy socialising which takes place with such use.
124, The presence of sport and recreational officers and such facilities, as those at Nguiu, are a positive, every day practical resource which should be encouraged.
126, [further submit that the Coroner should recommend that the practical and preventative value of youth and community recreational
and sport facilities should be considered an integral part of the community and that there be an all of Government approach to the
development of positive life-giving j ces on the community.
a7
the role such sporting facilities play and encourage the development of such facilities at Milikapiti and Pirlangimpi,
A swimming pool is expected to be installed next year, This too will provide a healihy exercise and recreational venue for young people to gather. So too, a scout troop is being formed. Mr Barclay said that this troop is the first indigenous scout troop. Thesc initiatives should be encouraged as they help create purpose and focus for healthy living.
The school children expressed keen interest in the re-establishment of the blne light disco. This is an option which community and
Government planners should consider.
suicides this initiative is supported.
There needs to he an attitudinal change by many in relation to the role
of alcohol and marijuana in Tiwi society. Change will not be easy, but it is submitted that Dr Parker is correct when he commented that such
change is necessary. Ultimately, only Tiwi people can be responsible
for their own future. However, they do need help.
Programs, strategies and practical efforts which enhance public health and safety in an immediate and long term manner need to be revamped and given the opportunity to be effective. Clearly the development of a suicide prevention strategy which is adaptable to Tiwi people is an initial and urgent priority. The identification and coordination of existing resources and consideration of what other measures are necessary, seems to be a logical adjunct to this,
Support for Aboriginal health workers and others who work in the field needs urgent consideration by THS and the Tiwi Health Board.
Issues such as bur out, work overload and lew moralc nced to be addressed and catered for in practical ways.
Further, the Tiwi Health Board itself needs community and Government support.
Perhaps, at the vanguard of the need for change, is the necd to address alcohol and marijuana abuse, If the evidence of this inquest suggests anything, it is that alcohol and marijuana abuse are destructive of all current attempts-at ameliorating the unacceptable suicide and attempted suicide statistics.
Ifsuch substance abuse can be brought into check, what then would
be a good outcome of this inquest is the implementation of successful suicide prevention programmes in the Tiwi communities,
C.R McDonald Q.C
Counsel Assisting
STATUTORY DECLARATION I, Peter Maxwell Cumming OF Pirlangimpi Police Station Date and Place Of Birth 24/11/69 Albany W.A.
Oecupation Police Officer Subject Coronial Enquiry — Deaths at Nguiu
}, Peter Maxwell Cumming
Of Pirlangimpi Police Station
Do solemnly and sincerely declare that : y
| have been a member of the Northem Territory Police since February, 1987. Lhave = served at Darwin, Katherine, Timber Creek, Nhulunbuy and numerous communities | across the top end. On 1° September, 1998, | commenced duty as the Cfficer in Charge of Pirlangimpi Police Station. The district incorporates the Tiwi Islands with the communities of Nguiu, Milikapiti, Wurankiwu, Tarracumbie and Pirlangimpi.
Demographics
The population of the entire district is in the vicinity of 2,350 people at the following communities :
Negniu - 1,500 Milikapiti 450 Pirlangimpi 330 Wurankuwu 50 Tarracumbie ce
The majority of the population are Tiwi peuple, being aborigines from the islands (approx 80%). A further 15% of the population consists of persons of part aboriginal/ part Caucasian origin. The Tiwi people generally accept these people as being ‘Tiwi’,
The remainder of the population (5%) are Caucasians employed on the islands who generally reside at the communities for 3 years on average.
be
Employment/Fuiurc Prospects
The islands offer little in the way of employment opportunities. The majority of persons are employed on the CDEP progmimme or are on unemployment benefits, The local councils and housing associations employ people working on CDEP in a wide range of jobs from office duties, building through te general labouring.
Private enterprise does exist on the island, most notably with Sylvatech whe are a forestry/pulping business. Sylvatech has recently commenced operations on the islands and are employing Tiwi residents. The opportunities for employment with them should increase az the project develops and expands. Other private enterprise is small businesses such as Tiwi Tours who employ a small number of people.
Social Issues
The majority of the population lives from week to week financially. Mast people receive ininimum payments (unemployment benefits $180 weekly} and spend the majority of this on food, daily living expenses such as electricity, gambling, alcohol and cannabis.
There are four skin groups on the islands who are all inter-related. As such there is a strong relationship between the proups that provides little friction. I have found the people to be exceptionally friendly towards non-Tiwis and co-operative with police generally.
From my experience, the peopte of the Tiwi Islands have a better standard uf education than other communities in the Northern Region. This being the case however, very few people speak English fluently and some speak English to such a limited extent that interpreters are required for simple communication with non-Tiwi persons, The majority of the community speaks English to a standard where ihey understand mast of what is being said and can relate that back to you.
The use of alcohol and cannabis is high within the population. Both are well aceepted means of entertainment on the island and are used as a means io alleviate boredom. The consimption of beer is regarded in such high esteem that the removal of that privilege is the primary means of discipline upon the islands.
There appears to be a large problem with a break down in traditional cultural valuos. The ‘extended famify’ sirncture used within the community (and all other aboriginal communities) is creating complex social problems for individuals. The Tiwi people appear to have a strong set of rules upon which the foundations of their society are made.
The application and enforcement of these rules does appear however to be waning.
— " TD. Meme.
As the Tiwi people attempt to come to terms with ‘modern Enropean society’ in a relatively short period of time, they appear to find conflict between traditional lore and the values and expectations of European saciety.
The result of this is apparent in everyday iiving throughout the islands. Respect of traditional elders is declining within the younger generation, family heads are ne longer in control of their children and the valuc of cultural living is being lost. Persons of a traditional background are unable to provide support or advice for those embarking upon this change in values because they do not understand the reason for change.
Police Issues
Two ‘European’ police and three Aboriginal Community Police Officers staff the Tiwi islands. The European police are based at Pirlangimpi, two ACPO?’s are based at Nguiu am] one ACPO ai Milkapili. The numbers of police on the island are.sufficient to deal with the workload.
By far, the majority of problems (as apposed to crimes} on the islands relate to ; disturbances. These are generally resolved by the ACPO’s in conjunction with family : groups. Most disturbances involve the commion theme of jealousy between a couple or arguments over family issues. The majority of disturbances that come to police attention have alcohol involved ag a contributing factor. (As a rough cstimatc 85%)
There arc three crimes conmniticd on the islands that make up the largest proportion of police investigations. In order of prevalence they are Criminal Damage, Aggravated Assaults and Unlawtal Entry/Stealing oMfences.
Young males (16—25 years) who are intoxicated and have been involved in an argument or fight commit the majority of Criminal Damages. They smash vehicle windsercens or glass windows in frustration or as a means of demonstrating their anger to the community.
Aggravated Assaults ocour betyeen couples (Domestic Violence). They invelve alcohol in at least one of the combatants (usually the offender) and are indicative of the social pressures upon individuals within the community.
Unlawful Entry/Stealing offences always involve the ihell of foud or aleahol. It is the primary reason for the unlawful entry. Occasionally personal property is stolen however these are taken because of upporiunity once inside the premises.
All unlawful entries are committed by males, tho majority by young males (10-18) who
state a3 the principle reason for the unlawful entry that they were hungry or wanted alcohol.
Suicid
nicides ann + pp Since { commenced duty on the Tiwi Tslands there have been five sueceesftll suicides, aes are the subject of this enquiry and two recent suicides that are still under
investigation.
Although not subject to this enquiry, I feel it is important to use information gained from the recent suicides as a comparison for my cbservations of the ibAgF Suicides under review.
Of the five suicides 2 have involved the syndrome of ‘clustering’ and after the initial suicide a second suicide occurred in a short period of time.
Of the five suicides 4 were committed by hanging and 1 hy chmbing a power pole.
All five suicides involved conflict within the family group.
Of the five suicides 4 persons were drinkers and three of these 4 had been drinking.
OW the five suicides 3 persons were known to be cannabis users but it is not known it they were under the influence of cannabis at the time. ’ All five peeple had threatened to commit suicide at an eariier time.
All fve were under the age of 25.
“a 2. pe .
Trely upon these facts to support my belief that actual suicides that occur are evidence of the breakdown within aboriginal society. This is aparrent from the young ages of those who suicide. | however am not qualified to give full reasons for this breakdown, least of all a solution to it.
In examination of these statistics, it seems that being intoxicated has contributed to the state of mind that results in the act of suicide, Cannabis use amongst those that committed suicide is also an influential factor, however I am unable io say whether the person had been smoking cannabis prior to the act or if their long term usage of cannabis had caused a change in their personality that contributed to their state of mind.
From my observations men within Tiwi society use alcohol in larger amounts than women. Asa result mon are the cause of the majority of disturhances within the communities. In addition, greater pressure 1s placed upon them by their spouse and farnilies to minimisc thew drinking. This pressure is shown in the high level of male suicides.
The phenomenon of ‘clustering’ has occurred in two of the three suicide evenis. When a person suicides the community treats the death of that person with the same honour as a death by other means. By comparison in European society a death within a family by suicide is seen ua tragic but it also holds a degree of shame.
/r~. SD. Howe
When the first suicide occurs within the community, there is much talk amongst the people of the person who has died, The person is honoured and the catire community is focussed upon that person. This creates a desire within the community for something that ig missing in daily life — attention and love. As a consequence a second suicide has occurred in both occasions, interestingly hy the same means. It is my belief that the second suicide victim had an emotional nved to receive the same ‘idol’ status as the suicide victim before them, It is inconsequential that they are not there to see those benefits.
Allempted Suicides There needs to be recognised that there are two types of ‘attempted suicide’. They are :
® Where 2 person has a genuine desire to kill themselves and are stopped whilst in the act or from committing the act. :
Ttis difficult to give an accurate number of aitempted suicides that have occurred on the
islands. I shall address the reasons for this in the subject of Recommendations.
! can however state that since taking up my position on the Tiwi islands, police have been called to over 50 suicide attempts. This figure may seem horrific but it is in Fact only the tip of a very large iceberg.
As the court may be aware, other persons on the islands have collected statistics some of which far exceed the 56 1 have mentioned. As an exaniple, the power at Nevin community has been cut over forty times duc to a person climbing power poles. Some of these incidents are bought to police attention others are nat.
There are only three types of suicide threats that I have heard about on the islands. The tmost common is climbing power poles followed by hanging and lastly and very tarely by swimming out to sea. :
It is interesting that by far the greatest threat is by electrocution (as an estimate 70%)
‘however only 1 of the 4 suicides involved a power pole, ‘The second highest threat,
hanging (28%) has been the cause of 4 of the 5 suicides, Swimming out to sea has been the subject of police attention however there has nevet been any real concern for the persons safety as they usually swim buck by the time police arrive.
It is my belief that persons who attempt to hang themselves have a genuine desire to kill themselves. They mostly tell someone they are going to kill themselves and usunlly are only discovered by the fact they have warned someone. J believe this is the “Cry for Help” syndrome that is common in many suicide attempts Australia wide. If it were not for the fact they told someone beforehand they would increase the suicide Tate
dramatically, There have been two cases of people climbing power poles and being electrocnted since T have been stationed at Pirlangimpi, neither of which police attended.
In both cases a large crowd had gathered below the power lines and the person then grabbed the lines before they could be stopped, I belicve this too is a “ory for help”,
The other cases of reported suicide attempts I believe are done for an entirely different tnotivation. An example of this is putice at Nguiu were called as a result of a domestic dispute. The offender decamped the area and climbed a power pole. He then threatened to Kill himself untess two demands he made were accepted, The demands were that his wife not make any form of complaint against him and secondly that police leave the urea, Once police left the area the person climbed down from the pole and made up with his wife,
This example is an extreme one of what happens ona daily basis within the islands, T would conservatively estimate that since being stationed at Pirlangimpi police have been involved in or heard about at least 3 cases of this a week. After a suicide the incidence af this increases. Since the most recent suicides, I have been mado aware of 6 attem pts along these lines in a matter of & days. :
I believe the masons for threats to kill oneself’ are manipulation. It is a commonly used tool by people to obtain results when other means of negotiation have been unsnecessful.
It should he noted however that although the principle aim of this tactic is a personal gain there is the underlying principles of other suicide attempts in their threats.
As a result, the probability of the person who threatens to commit suicide, for whatever means actually committing suicide is very high, This is shown in that all of the persons who committed suicide had threatened (v do so previously.
Police Response
The risk of a death in custody is exceptionally high on the Tiwi Islands, Ag such the attitude of police is to incorporating a community Tesponse rather than a police response to problems ubrough a four step process:
The farnily of the offender in consultation with the victim should firstly address an issue in an attempt fo reconcile their differences.
Should the family or victim be dissatisfied with the result the ACPO or night patrol} should be contacted to pravide assistance,
The ACPO should attempt to resolve the maller in a culturally and legally correct manner, If they are unable to do so, Pirlangimpi police are contacted,
Pirlangimpi police will investigate all matters reported to them and altempt to resolve them locally. If this cannot be done, the matter is subject to prosecution.
( .* “D- Maw
~4
In addition to minimising the risk of persons in custody, the aim is to make the community aware of it’s own problems and attempt to resolve the issues finding a balance between cultural values and European Law values.
The method is proving successful in finding an adequate punishment to fit a particular incident however it is not reducing the cause of such incidents as was hoped at it’s introduction. It appears the answer to this is the presence of police to act as a deterrent.
Currently Pirlangimpi police travel to Nguiu on a Tuesday and remain avemight leaving on Wednesday afternoon. Friday ig committed te patrols of Milikapiti. Mondays and Thursdays are committed to administrative work at Pittanyimpi.
In analysing the workload af the entire district, 75% of the work originates at Nguiu. This ix not sirprising considering the large proportion of the Tiwi community living there.
Milikapiti creates 25% of the workload and Pirlangimpi a there 5%; It is my submission that Milikapiti’s workload would decrease and Pirlangimpi’s would increase if the police were stationed at Milikapiti rather than Pirlangimpi.
Since | have been stationed at Pir! angimpi, [have not been fo a suicide there or what I believe to be a genuine “cry for help” attempt. | have however, been to numerous manipulative suicide attempts.
Of the five suicides, | has been at Miltkapiti. I am aware of numerous “ory for help” suicide attempts and countless manipulative attempts.
By far the greatest number of suicide aliempts is at Nguiu. I believe the number of attempts is in proportion with Milikapiti relative to their teapective sizes. Nauiu has had four suicides since I have been stationed at Pirlangimpi and a threat of suicide is a daily event.
It is my opinion that a ‘European’ police presence should be established permanently at Nguiu. The presence of police does si gnificantly improve the behaviour of members of the community as is evidence by the level of erime and reduce suicide attempts at Pirlangimpi, This is not through any fear of the police, but because the police are known to investigate matters fully without favour. Police ure also in the Position te be able to resolve an incident when called instanily when called for.
The use of cannabis on the islands is of high concern to all police working on the island.
Police are substantially handicapped in the investigation of drug offences by primarily a lack of information. Very little dmg information is passed on to police and this is possibly because of the high level of acceptance of its’ use in the community.
The information provided to police is limited and reasonable intelligence of suspects thovements cannof be gained because police are not Present within the community for the majority of time. Offenders know the police schedule and can time delivery’s for when police are absent.
Air North, the principle carrier to the islands have recently introduced a programme with the assiatance of the Liquor Commission. As a result 100% random searches are conducted of passengers luggage. This programme should be commended for its impact upon the smuggling of alcohol and drugs onto the island,
Unfortunately, many goods are shipped to the islands via Tiwi Barge or private air charter companies. As such it is impossible for police to check all cargo and there is insufficient information to target a particular person.
Police have previously searched bags at the airports on the island at random intervals for alcoho] and drugs. This action does nat occur anyiore 48 complaints were received fom the public. In addition a prosecution case may have difficulty establishing reasonable grounds for the search in accordance with the Liquor Act, Misuse of Drugs Act or the Police Administration Act. .
Thave executed 6 search watrants for drugs in the past year. Of them only a minor acount of cannabis has been seized, and inall cases the offender issued with an infringement notice for Possess Cannabis, : Thave received notification on four occasions from Customs in Darwin of drugs being conveyed to the island in baggage or freight. All four persons have been proseculed for possessing cannabia. .
Intelligence on the drug issue however, suggests that police are missing the majority of cannabis being imported to the islands. It appears that when dealers bring cannabis to the island it is sold within the day and police receive information weeks later.
Members of the community do not see alcohol, which is undoubtedly the major contributing drug to suicides as a problem. The Tiwi Islands are a restricted area however Nguiu, Mikkapiti, Pirlangimpi and Wurankuwu all have clubs with different laws in relation to the takeaway provisions of legislation. The clubs are goed in that they minimise the smuggling of alcohol and give the people an opportunity to drink socially, Overall the clubs are run very well with minimal problems.
Takeaway alechol is banned at Nguiu and Wurankuwu. At Milikapiti permit holders are allowed six cans of heer per person per day as takeaway sales. Ai Pirlangimpi takeaway sales are not restricted if a person holds a permait to do go. Tt is my belief that uniform takeaway laws should apply to the entire islands to inimtnise alcohol abuse, J have raised this matter, particularly at Milikaptli which has a large social dri king problem in order to improve the lifestyle and safety of the communily. The community has rejected this suggestion, instead wishing to raise the level of their takeaway consumpiion rather than decrease it,
eo. "D+ Megs.
Recommendations
While attempting to find a reason behind suicides on the islands [ have spoken to many sources. The reasons given are varied however all follow a common theme of social disorder and drug problems.
I earlier mentioned that there is a problem in collating statistics on attempted suicides, This is because each comnmunily deals with it’s own issues separate from the other communities. In turn government departments such as the Police, Family Youth and Children’s services and Education are not co-ordinated with other services such as the Tiwi Health Board, Tiwi Land Council, the Catholic Education Office or local councils.
As such, everybody is aware of the suicide issue and [ believe all groups are working positively towards the issue. However an individual acting independently or an organisation acting independently will noi be able to effectively deal with the problem.
This is because they do not adequately address all aspects of the issue. A co-ordinator should be employed by the Tiwi Health Board, F amily Youth and Children's Services or \ the Tiwi Land Council to focus on the issue of suicides, This person then needs to .
harness the resources of all agencies towards the problem.
The major cormpynent of the suicides {as evidenced in all dive suicides) is family disputes. There is a desperate need for a counsellor who resides on the islands and travels exiunsively to all communities on a weekly basis. When speaking to Tiwi people however, they all state that itis important that this person be a Tiwi as only they understand what all the problems are. J believe this to be true, however I am not aware of any Tiwi person’s qualified to offer professional constructive counsel ling. The answer must therefore be in a non-Tiwi wha works closely with Tiwi slaff. The counsellar should be able to address issues dealin with parenting skills and lifestyle management.
It is important however thal ihe community’s capacity to deal with it's own problems is increased. Currently the community relics on government agencies and experts to provide a ‘band aid’ solution.
The Power and Water Authority have placed barricts around power poles te minimise the chances of people climbing to the wires. This has been unsuccessful however as the design allows people to ¢limb over the barrier (albeit with some pain involved), The bartiers may minimise the number of persons climbing poles but they are not preventing people ftom climbing them. The design of the barriers needs to be reviewed.
An education programme within schools needs to be developed encouraging resistance to drugs. In addition however life skills need to be developed for children in an attempt to avoid the cycle of social breakdown. An application has been made for a school-based constable to work within the schools of the islands, ‘his position would requite a large amount of time but could be rin from Darwin.
id
The islands require an alcohot and drug program specific to the needs of the Tiwi people.
A sobering up shelter would be justified at Neuiu which incorporates an alcahol program similar to that of groups such as AIMSS or FORWAARUD. Not only would this provide employment for Tiwi people, it would become a community based program that helps their own people.
The community sometimes punishes people who threaten to commit suicide by methods such as banning from drinking. This method is not positive and does nothing to prevent the recurrence of the threat of suicide. The clubs and people should rather be encouraged towards the consumption of lower alcoholie content beers to reduce community problems. A government based group such as Living with Alcohol should be encouraged to introduce programs within the communily with this objective in mind.
Sport and recreation in the community also needs to be encouraged. Boredom is a large factor in alcohol abusc and drug usage, .
Thave attained the age of 18 years and | have read this statement before si ening it.
I make this solemn declaration by virtue of the Oaths Act, ceuscientiously bel ieving the statements contained herein to be true in every particular, ;
Declared at Pirlangimpi this 8"* day of November, 1999.
fo ~ Before me : RY Mass P.M. Cumming D.8. Moore Commissioner for Oaths (NT)
Ph : 89783969
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