Inquest into the death of Kumanjayi Walker

ATTORNEY-GENERAL

Parliament House GPO Box 3146 State Square Darwin NT 0801 Darwin NT 0800

REPORT TO THE LEGISLATIVE ASSEMBLY

Pursuant to section 46B of the Coroners Act 1993

In the matter of the Coroner’s Findings and Recommendation regarding the death of Kumanjayi Walker

Pursuant to section 46B of the Coroners Act 1993 (the Act), | provide this Report on the findings and recommendations of Local Court Judge Elisabeth Armitage, Territory Coroner, regarding the death of Kumanjayi Walker (the Deceased) (Attachment A refers).

This Report includes the responses to the recommendation of the Territory Coroner by Mr Luccio Cercarelli PSM, Chief Executive Officer (CEO) of the Department of the Chief Minister and Cabinet (CM&C); Mr Chris Hosking, CEO of the Department of Health (DoH); and Mr Martin Dole APM, Commissioner of Police, Northern Territory Police Force

(NTPF).

The Deceased was a 19-year-old Warlpiri / Luritja man who died at the Yuendumu Police station on 9 November 2019, due to gunshot wounds to his chest and abdomen.

Recommendations of the Coroner

The Coroner made the following recommendations regarding the death of the Deceased at paragraph 1734 of the Report:

'To the Northern Territory Government

To the Minister for Aboriginal Affairs and Community Development; Attorney-General; Minister for Education and Training; Minister for Children and Families; Minister for Youth and Disability; and/or other relevant Minister.

1. The Northern Territory Government convene a meeting with local Council and service providers to provide and implement the expansion of night patrol in Yuendumu, with a focus on training local employees to deter youth crime and link young persons/offenders into services, and diversion programs.

2. The Northern Territory Government review the availability of youth services in Yuendumu (including the closure of WYDAC). and develop and implement a plan to support sustainable youth services with good governance. to be designed in consultation with community representatives.

Seis NORTHERN

aan Laelia: Lag

As part of a review into youth services in Yuendumu, in consultation with the community, the Northern Territory Government plan for and implement services targeting engagement with: young people who have engaged in offending; young people with disability, and young people who have dropped out of school, with a view to reducing offending behaviour.

The Northern Territory Government train and adequately resource culturally skilled mediators, such as the Southern Tanami Kurdiji, to be available permanently, in Yuendumu. Those mediators should be trained and remunerated to work in conflict resolution processes, including to assist to resolve conflicts caused by:

(a) crime suspected to be committed by youth and young adults;

(b) tensions between police and community members; and

(c) tensions between service providers (including police, school and clinic) and/or service providers and community.

In consultation with the community of Yuendumu, the Northern Territory Government provide for Aboriginal-led, on-country programs, rehabilitation and diversion services for young people with substance abuse issues who come into contact with, or are at risk of coming into contact with, the criminal legal system (for example, the Mirrilingki On-Country Drug and Alcohol Program).

The Northern Territory Government undertake a consultation with the community of Yuendumu to determine whether there is broad support for the Parumpurru proposed establishment of a single, elected, remunerated, leadership group in Yuendumu as a means of providing community control over the delivery of services.

if the establishment of the leadership group referred to above is sufficiently supported, then the Northern Territory Government should:

(a) implement the leadership group, including by providing governance training and support;

(o) consider specific requirements for good governance for such a group, such as at least two (2) independent board members from outside the community; and

(c) together with the elected leadership group, co-design the groups ‘terms of reference’.

The Northern Territory Government, together with the elected leadership group or (if one does not yet exist) community representatives, co-design a 10 year plan for youth and young adults in Yuendumu, including a mapping report for the resourcing required to achieve goals for reducing criminogenic factors affecting young people. The 10-year plan should set out goals and a timetable, as well as a mechanism for annual reporting on meeting objectives, and should include:

(a) youth wellbeing and opportunities for youth engagement:

(b) school retention and re-engagement of children not in attendance;

(c) specific plans for reducing crime committed by youth and young adults;

(d) sustainability of youth services:

(e) culturally appropriate mediation services involving or relating to youth; and

(f) strategies to reduce alcohol/cannabis consumption and supply.

The Northern Territory Government introduce amendments to the Police Administration Regulations, or elsewhere as required, to implement mandatory drug and alcohol testing of a police member after a critical incident similar to other jurisdictions in Australia.

The Northern Territory Government convene a committee of leaders from relevant funding and service providers, including Aboriginal Community Controlled Health Organisations, to develop a strategy for strengthening the provision of culturally competent and sustainable mental health services in the Central Australia Region, including Yuendumu, That strategy is to be made to be publicly available, its implementation is to be regularly evaluated and it is to include plans for:

(a) specialist services for young people;

(b) recruitment for services on country; and

(c) pathways for Aboriginal employees to be engaged, trained and adequately remunerated as mental health specialists.

The Northern Territory Police Force

Territory Police Force is to engage with the Yuendumu elected leadership group or (if one does not yet exist) community representatives such as any Law and Justice Group, the Parumpurru Committee and the Southern Tanami Kurdiji, to develop a Mutual Respect Agreement with Yuendumu (and with other consenting remote communities) including identifying the circumstances when it would be appropriate for police not to carry firearrns in community, and in relation to the deployment of the Dog Operations Unit.

The Northern Territory Police Force is to take all steps necessary to ensure that, except for the lawful destruction of an animal, general duty members do not openly carry AR-15 semi-automatic assault rifles or other similar weapons except with documented prior approval by a Senior Sergeant (or above} or in an emergency.

The Northern Territory Police Force is to ensure that there are clear policies and procedures in place for specialist units addressing circumstances when the open carry of AR-15 semi-automatic rifles or other similar weapons is (or is not} permitted, and a process for how that is to be operationally determined and documented.

The Northern Territory Police Force is to train its members, and incorporate into its policy and procedures, that where culturally appropriate and operationally feasible, it is best practice for a frontline NTPF member to consult or liaise with an ALO or ACPO, including as to the desirability of an ACPO's presence, in any planned interaction or arrest of an Aboriginal person. This consultation should include identification of the Aboriginal person’s known vulnerabilities (if any), and planning focused on a trauma-informed/de-escalation/minimisation of force approaches.

The Northern Territory Police Force is to incorporate into (scenario) training of new NTPF recruits, the circumstances of Kumanjayi’s death as an example of the danger to officers and the community when there is insufficient arrest planning, and as an example of “officer induced jeopardy”.

The Northern Territory Police Force set up a working group with representatives from the main relevant agencies (including a senior member of the Cultural Reform Command (CRC), a senior member of the PSC, NAAJA, NT Legal Aid, the Ombudsman, and Anti- Discrimination Commission) to develop and implement improved procedures for addressing complaints made by Aboriginal people about police use of force and/or allegations of racism, including time frames and communication protocols.

The Northern Territory Police Force amend the process for evaluation of complaints to require the PSC to liaise with or consult a Cultural Reform Command (CRC) member of the rank of superintendent or above before finalising the investigation of a complaint. The General Order ‘Complaints Against Police’ should be amended to give effect to this change.

The Northern Territory Police Force take measurable action to ensure that PSC investigations are determined in a prompt and efficient manner, and to identify and implement changes that ensure the mental health and wellbeing of a police member under investigation is supported. This should include:

(a) developing appropriate time frames for the completion of an investigation that are clearly set out in relevant policies and procedures;

(b) transparent annual reporting on whether time frames are being achieved; and

(c) embracing changes to the disciplinary process to implement the stated commitments to a managerial approach (as recommended in the Galliott report commissioned by NT Police).2006

The Northern Territory Police Force, ensure that the “Anti-Racism Strategy” that is being developed by the Cultural Reform Command (CRC), is published on the Northern Territory Police website and includes:

(a) a consideration of ail policies, procedures, training and recruitment: co-design and input from the Aboriginal Community and legal service sector, and a stated aim of ensuring the safety of Aboriginal people;

(b) the stated NTPF commitment to reaching a 30 per cent Aboriginal proportion in the workforce;

(c) the stated NT Police commitment to a significantly increased level of Aboriginal leadership; and

(d) ongoing six monthly publication of reports tracking progress in recruiting, retaining and promoting appropriately qualified and experienced Aboriginal staff in different roles and ranks across the force.

The Northern Territory Police Force is to take steps to move the Cultural Reform Command (CRC) to a command structure of equivalence to the Domestic Violence and Youth Command, namely, led by an Assistant Commissioner with the power to give members directions, so as to ensure that NT Police remains committed to the Anti-Racism Strategy and training for future generations and to ensure that Anti-Racism Strategy and training continues to receive the priority it demands.

Recognising that the Northern Territory Police Force has recently introduced a new training session called the “Policing Mindset” for recruits (encouraging recruits to consider how their past professional skills and experiences might subconsciously affect their policing decisions, and the differences between using force in NT Police compared with other police forces or agencies such as the ADF) this is to be evaluated at the end of a 12 month period, and if positive, embedded as training for recruits. If the evaluation identifies that the training is not effective, alternative training is to be implemented and evaluated.

Recognising that the Northern Territory Police Force training College is engaging an external provider to deliver a trauma informed program which includes intergenerational trauma in a youth context, this training program is to be evaluated within 12 months of its introduction, and if positive, the program is to be embedded in recruit training and made available to current serving officers.

The Northern Territory Police Force is to develop and implement induction packages for all police locations. This process is to be facilitated by the Cultural Reform Command (CRC) in consultation with local members, ACPOs and ALOs. Induction packages should contain information about cultural considerations, including practices, obligations, language, familial relationships, and significant contact points in the community. Such packages should be subject to annual review by CRC, with the assistance of the community advisory group or (if it does not exist) elders in community.

The Northern Territory Police Force is to ensure that its General Order concerning a death in custody outlines clear investigative structures and procedures for when criminal and coronial investigations run side by side.

The Northern Territory Police Force should develop a debrief and weifare policy which:

(a) makes it clear that police witnesses to deaths in custody are to be separated from other witnesses (including police witnesses) as soon as practicable after an incident until their staternents are obtained,

(b) provides for a consistently followed debrief process for death in custody incidents, including where there is a possibility that a criminal investigation will precede a coronial one for example, private and/or group debriefs (whichever is operationally appropriate) led by an expert facilitator, such as a psychologist.

(c) includes member witnesses whenever investigative parameters permit;

(d) facilitates operational learning;

(e) provides for sufficient professional and peer welfare supports to be made available to all police witnesses, preferably immediately after an incident or as soon as practicable within 24 hours of an incident; and

(f) — (f} ensures confidentiality.

Recognising that the Northern Territory Police Force has recently introduced a new “Early Intervention Policy” to identify members whose performance, wellbeing or behaviour is problematic or raises “red flags”, and which provides for “early intervention conversations” and other assistance measures; the Northern Territory Police Force is to thoroughly evaluate the effectiveness of the policy after 12 months and take all steps necessary to strengthen and resource the full implementation of the policy if weaknesses are identified.

With respect to the new “Early Intervention Policy’, the Northern Territory Police Force is to ensure that all members identified for intervention are, in the initial intervention, offered professional and/or peer welfare support, appropriate to the members situation.

The Northern Territory Police Force is to establish a policy which aims to ensure that all members achieve a minimum of four months continuous remote posting in their first three years of employment in NT Police. The policy should identify the kinds of exceptional circumstances that may preclude a member from completing such a posting, for example, contractual requirements, health conditions, or specific family obligations that cannot otherwise be accommodated.

To NT Health

NT Health take all steps necessary to ensure its primary health care service providers (remote and major} screen all children under 5 years of age, who are accessing a NT primary health care service, using the ASQ (Ages and Stages Questionnaire) development assessment tool or the culturally adapted ASQ-Trak, or an appropriate equivalent developmental screening tool.

With respect to that screening, NT Health should ensure that:

(a) the screening of each child is to occur as often as is recommended by the screening tool:

(b) any child identified with results which may indicate FASD, is to be referred and followed up for an early childhood intervention plan under the NDIS and a FASD assessment;

(c) both screening amd referrals are to be included in the services Key Performance Indicators (KPIs);

(d) every effort is made to work with Aboriginal Community Controlled Health Organisations, Territory Families, the Department of Education, early childhood service providers, and any community leadership group, to promote screening and referrals of all children.

NT Health strengthen its implementation of the Remote Engagement and Coordination Strategy and work to strengthen Local Health Advisory Groups (LHAG), with additional priority in Yuendumu, to ensure that:

(a) there are set periodic meetings between remote Primary Health Care Centres and the LHAG for which attending LHAG members are remunerated;

(b) there are centre specific strategies in place to improve engagement between non-Aboriginal staff and community members, and between non-Aboriginal staff and Aboriginal staff;

(c) the LHAG is consulted on location specific cross-cultural orientation,

(d) all new staff (Aboriginal and non-Aboriginal) have participated in a cross-cultural orientation which includes information specific to their place of employment;

(e) there are centre specific plans in place for the inclusion of cultural consultation and engagement when decisions are being made about how to resolve challenges/problems that arise in remote communities (including, for example, unlawful entry into houses); and

(f} there is consultation with the LHAG on centre/focation specific plans concerning any withdrawal of NT Health services, whether temporary or permanent.

In consultation with its Northern Territory Government counterparts, and other community stakeholders NT Health revise its Temporary Withdrawal Guideline to ensure withdrawal is a last resort and is to take place only after consultation with Aboriginal staff and community stakeholders. Once formulated, NT Health is to:

{a} publish the guidelines on the NT Health website; and

(6) implement a policy to promote awareness of the Temporary Withdrawal Guideline, particularly amongst leaders and elders in remote communities.

32. NT Health and its remote Primary Health Care Centres actively participate in, promote, and, where necessary, initiate and develop, additional forums for collaboration with remote community groups, such as the local community council, schools, police, any community leadership group, and non-government agencies to share information and address local issues, including staff safety.

To that end, NT Health should:

(a)

(b)

(c)

ensure that the conveners of forums such as the Regional Coordination Committee and the Community Safety Action Plan Meetings have up to date contact details for the relevant NT Health remote Primary Health Care Centre;

ensure that the NT Health centre is on the notification list for meetings; and

ensure that NT Health remote Primary Health Care Centres maintain their own records of attendance at meetings, together with the agenda and/or minutes.

NT Health should strengthen recruitment, professional development and support of its Aboriginal staff, particularly in remote Primary Health Care Centres, including by:

(a) (b)

()

‘Recommendation 1

increasing and supporting access to cadetships;:

increasing and supporting access to the basic skills Aboriginal Health Worker training; and

strengthening pathways for Aboriginal health workers to become Aboriginal Health Practitioners.’

Response to Coroner’s recommendation

A copy of the Coronial Findings was provided to Mr Cercarelli on 6 October 2025, for a Northern Territory Government response, in accordance with section 46A(1) of the Act.

Awritten response was received from Mr Cercarelli dated 5 January 2026, as required by section 46B(1) of the Act. The response was as follows:

Funding for night patrols in the Northern Territory varies by community and region.

In Yuendumuy, the night patrol program is delivered by the Southern Tanami Kurdiji Indigenous Corporation (STKIC) and funded by the Commonwealth. In 2025, STKIC received funding through the Remote Jobs and Economic Development program from the Commonwealth National Indigenous Australians Agency (NIAA) to create 26 new employment opportunities in Yuendumu, including community safety

patrollers.

The NT Government will continue to work with local council and service providers in Yuendumu to build the capacity of local employees to deter youth crime and link young persons/offenders into services. and diversion programs. This includes employees of the CDRC and STKIC.

Recommendation 2

In 2024, the Northern Territory Government in collaboration with local councils and NIAA, undertook a service mapping of Central Australian communities. This mapping project identified emerging trends for service delivery across regions, including Yuendumu.

Based on the mapping exercise and further work to assess the effectiveness and efficiency of individual youth programs and services, the NT Government will identify opportunities to strengthen the service system in Central Australia, including in Yuendumu, to improve coordination, liveability and outcomes. This includes working with youth service providers to design, plan and deliver services that respond to community needs and priorities.

Recommendation 3

The Northern Territory Government delivers a range of services for young people in Yuendumu, including services that target young people who have engaged in offending, those with disabilities and those who have dropped out of school.

This includes mainstream services, such as health, early childhood, and education.

For instance, programs delivered through schools targeting early learning initiatives, improved school attendance, improved student outcomes and a range of flexible education programs for young people at risk of disengagement.

The Northern Territory Government also provides support to external providers to deliver youth diversionary services (the Men's Advocacy Network); disability supports; and sport and recreation activities delivered through the CDRC.

Further planning and delivery of youth services in Yuendumu will occur through formal partnerships and shared decision making with local communities ensuring priorities reflect contemporary needs expressed by communities.

Recommendation 4

The NT Government is undertaking a range of actions to improve community capacity to respond to justice issues, including through the resourcing of culturally skilled mediators.

For example, the Attorney-General’s Department provides mediation support through the Community Justice Centre and the Commonwealth funded Mparntwe Peacemaking Project to assist in resolving community conflict across Central Australia. NIAA is also funding the STKIC to develop and deliver community-led mediation services in the region, which may include Yuendumu.

Recommendation 5

Yuendumu is a priority location under Northern Territory Health's (NT Health) Community Led Solutions project, aimed at empowering communities to plan, develop. and implement targeted strategies that reduce alcohol-related harm while enhancing community safety and wellbeing. Yuendumu is also a priority location for engaging an Aboriginal Community Controlled Health Organisation to provide place-based social and emotionai wellbeing support to the community.

NT Health provides support in areas such as withdrawal management; AOD psychoeducation; and community safety and community capacity building. NT Health also commissions the delivery of residential rehabilitation and bush adventure therapy in remote locations, including Yuendumu.

In 2025, the NT Government also introduced a structured community-based sentencing option for young people called the Sentenced to a Skill Program.

The program provides skills development and supervision to support young people sentenced to a community-based youth justice order to meet their legal obligations, reduce the likelihood of reoffending, and build pathways into education and employment. In Yuendumu, it is delivered by the Central Australian Youth Link-Up Service, in collaboration with the STKIC and the Australian Childhood Foundation.

Recommendation 6

Through the NT Government's empowering the bush agenda, DHLGCD is leading consultation across the Territory in 2026 on mechanisms for local governance and leadership. Community consultation will inform the direction and implementation of this priority.

Community governance mechanisms are currently embedded into key services in Yuendumu, including the Yuendumu Local Authority linked to the CDRC, the Yuendumu School Council, the Yuendumu Clinic Local Advisory Committee.

The STKIC and Granites Mine Affected Area Aboriginal Corporation are also Warlpiri governed bodies. A significant proportion of services are delivered through Aboriginal Community Controlled Organisations with associated organisational governance in place.

Recommendation 7

As noted in the response to recommendation 6, DHLGCD is leading consultation on mechanisms for local governance in 2026.

Recommendation 8

The Northern Territory Government supports community-led planning to provide local and place-based solutions for youth and young adults in Yuendumu that is designed in consultation with community and build on established planning already undertaken for young people in Central Australia, such as the existing Central Australia Youth Services Action Plan (the Plan).

The Plan was created by the NIAA and partners, including the NT Government to improve youth services for Aboriginal young people (ages 8-25) in Centra! Australia.

focusing on coordination, funding, and addressing gaps in sports, recreation. and life skills development.

Recommendation 9

The NT Government supports this recommendation and will progress the necessary amendments to policies and regulation through the usual processes.

-11Recommendation 10

An expert advisory group will be established for the Central Australia and Barkly regions, co-chaired by NT Heaith and Centrai Australia Aboriginal Congress.

Further initiatives to lift access to youth mental health services in Central Australia include the better distribution of resources and specialist expertise, co-investment with the Commonwealth in establishing a Medicare Mental Health Kids Hub, and an expert group led strategy for the provision of culturally competent and sustainable mental health services, including in Yuendumu, targeting young people and their families.’

A copy of the Coronial Findings was provided to the Commissioner of Police on 6 October 2025, in accordance with section 46A(1) of the Act.

Awritten response was received from the Commissioner of Police on 5 January 2026, as required by section 46B(1) of the Act. The response was as follows.

‘Recommendation 9

The Northern Territory Government supports this recommendation and will progress the necessary amendments to policies and regulation through the usual process.

NT Police position

° Accepted.

Work to date

° The proposed amendments are currently being reviewed.

Intended future work:

. Finalise associated policy, procedures and operational guidance to support the changes.

Recommendation 11 NT Police position . Accepted in part.

Work to date . The Implementation Committee has endorsed an in-principle position to engage with Yuendumu leadership and other consenting communities through existing Community-Led Safety Plans.

Intended future work

. Conduct structured engagement with Yuendumu's leadership group and relevant community representatives to discuss firearm carriage, Dog Operations Unit deployment and broader expectations of police presence.

e Utilise these discussions to better inform local, community-specific understandings about lower-risk or less visible postures, while retaining operational decision-making and officer safety responsibilities with NT Police.

Recommendation 12

NT Police position

. Accepted in part.

Work to date

° Operational Safety Section (OSS) has strengthened the relevant General Order (GO) to emphasise the need to carefully consider deployment of patrol rifles

and to treat deployment of any long arm as a reportable use of force subject to oversight and use-of-force reporting requirements.

Intended future work . Maintain and reinforce policy requiring documented approval by a Senior Sergeant or above (other than in emergencies) before open carriage of

patrol rifles, with continued training for users on justification, approval processes and reporting.

. Periodically review weapons policy and training to ensure accountability and proportionality in long-arm deployment.

Recommendation 13

NT Police position

. Accepted in part.

Work to date

. NT Police has reviewed specialist unit policies to ensure they address when open carriage of patrol rifles is operationally justified and to clarify authorisation and documentation requirements.

Intended future work:

. Continue to update specialist unit procedures so that any open carriage is

clearly justified under applicable policies, subject to defined approval pathways, oversight and recording.

-13Recommendation 14 NT Police position . Accepted.

Work to date

. NT Police has committed to training members and updating relevant General Orders and procedures to ernbed consultation with ALOs/ACPOs in planned interactions and arrests of Aboriginal people, including consideration of vulnerabilities such as medical conditions.

Intended future work

. Roll out ALO/ACPO consultation requirements through updated policy, operational guidance and training.

. Monitor uptake and effectiveness via operational reviews and feedback from frontline members and Aboriginal communities.

Recommendation 15 NT Police position ° Accepted.

Work to date

e The NT Police College has implemented the officer-induced jeopardy concept into several areas of recruit and in-service training, using real examples — including the circumstances of Kumanjayi Walker's death — to embed lessons in institutional memory.

intended future work

. Enhance training using scenario-based immersive platforms such as Avalanche and similar tools, building scenarios with stakeholders to combine officer-induced jeopardy, traurna-informed practice, policing mindset and situational awareness. Progress will be evaluated within 12 months of introduction and, if effective, further embedded.

Recommendation 16 NT Police position . Accepted.

Work to date

. NT Police has agreed to establish a multi-agency working group with the above partners to review and improve complaint procedures and to reflect this work within the Anti-Racism Strategy.

Intended future work ° Convene the working group to design improved complaint pathways, timeframes, communication protocols and transparency arrangements, with a focus on Aboriginal complainants and complaints about use of force and

racism.

. Integrate agreed changes into PSC policy, CRC guidance, training and public- facing information.

Recommendation 17

NT Police position

e Accepted.

Work to date

° NT Police has committed to the amendment of the complaints evaluation process to require PSC to consult a CRC delegate in complaints involving Aboriginal people or ajllegations of racism, and to update the Complaints Against Police General Order accordingly.

Intended future work

. Finalise and implement changes to PSC workflows and the Complaints Against Police General Order.

. Monitor compliance and impact on complaint outcomes and cultural safety.

Recommendation 18

NT Police position

° Accepted.

Work to date

® NT Police has committed to establishing clear timeframes for PSC investigations, implementing annual performance reporting and embedding a managerial approach consistent with the Galliott Report, while improving wellbeing support for members under investigation.

Intended future work

° Develop and implement PSC policies specifying timeframes, reporting requirements and managerial approaches.

e Build wellbeing supports into PSC processes and monitor timeliness and member feedback.

-15Recommendation 19

NT Police position

. Accepted.

Work to date:

° NT Police has developed an Anti-Racism Strategy and committed to finalising and publishing this document, with provisions for reviewing policies, procedures, training and recruitment, and setting workforce targets on the NT Police website.

Intended future work

. Publish the Anti-Racism Strategy and commence six-monthly public reporting on recruitment, retention and promotion of Aboriginal staff.

. Develop an Aboriginal Employment and Leadership Strategy to support targets for representation and leadership.

Recommendation 20 NT Police position ° Accepted in part.

Work to date ° NT Police has committed to ensuring CRC has sufficient authority, leadership and resourcing to drive the Anti-Racism Strategy, and considered options for elevating CRC's status considered as part of broader workforce design.

Intended future work

. Consider, through organisational design processes, whether to elevate CRC to an Assistant Commissioner-led command or equivalent senior structure, and implement any agreed changes.

Recommendation 21 NT Police position . Accepted.

Work to date

• NT Police has committed to the evaluation of the Policing Mindset module and adjustment of the curriculum to ensure unconscious bias and professional styles are effectively addressed.

Intended future work

e Conduct the evaluation, while refining or replacing the module as needed, and incorporating immersive learning platforms such as Avalanche to strengthen learning outcomes.

Recommendation 22 NT Police position . Accepted in part.

Work to date . NT Police has implemented trauma-informed training touchpoints within Domestic Violence and Youth and Mental Health training and is trialling virtual reality immersive learning in 2026 with ANZPAA support.

Intended future work:

° Evaluate the effectiveness of trauma-informed and immersive training within 12 months of full implementation and, if effective, further embed it in recruit and in-service programs.

Recommendation 23 NT Police position . Accepted.

Work to date

° NT Police has committed to the development of induction packages for all police locations, led by CRC.

Intended future work

. Design and roll out local induction packages with input from ACPOs, ALOs and community representatives, and establish an annual CRC review cycle.

Recommendation 24 NT Police position ° Accepted.

Work to date ° NT Police has committed to the amendment of its deaths in custody

General Order to specify clear investigative structures, roles and coordination arrangements where criminal and coronial investigations proceed in parallel.

-17Intended future work

. Finalise and implement the updated General Order and ensure relevant training and oversight arrangements are in place.

Recommendation 25 NT Police position: . Accepted in part.

Work to date: ° NT Police has committed to the development and implementation of a deaths in custody debrief and welfare policy incorporating structured debrief

processes, separation of witnesses, operational learning and timely access to supports, with confidentiality protected as far as legally possible.

Intended future work:

. Draft, consult on, and implement the new debrief and welfare policy. and integrate processes into operational and wellbeing practice.

Recommendation 26 NT Police position . Accepted.

Work to date:

° NT Police has adopted an Early Intervention Policy and committed to evaluate its effectiveness after 12 months in identifying and supporting members at risk.

Intended future work:

. Conduct the evaluation, address identified weaknesses and strengthen resourcing and implementation of early intervention processes.

Recommendation 27 NT Police position . Accepted in part.

Work to date . NT Police has committed to ensuring that members identified under the Early Intervention Policy are offered professional and/or peer support at the initial intervention, and to incorporate this requirement into policy and practice.

Intended future work

. Embed explicit welfare-support requirements into Early Intervention Policy documentation. training and monitoring.

-18Recommendation 28 NT Police position . Not accepted.

Work to date

° The Implementation Committee has considered and recommended rejection of a mandatory four-month remote posting policy, with the Commissioner advised accordingly.

Intended future work:

. NT Police will continue to encourage and support remote service where operationally appropriate, and to strengthen cultural capability through training, local induction packages, community engagement and targeted employment and leadership initiatives, rather than mandating remote postings for all members.’

A copy of the Coronial Findings was provided to Mr Hosking on 6 October 2025, in accordance with section 46A(1) of the Act.

A written response was received from Mr Hosking on 5 January 2026, as required by section 46B(1) of the Act. The response was as follows:

Actions NT Health has taken:

‘Recommendation 10

Progress to date:

Initial workshops have been held in Alice Springs and in Yulara between Aboriginal Community Controlled Organisations, Community leaders, NT Health and other invested organisations and Government Departments, co-lead by NT Heaith and the Central Land Council. Further workshops will occur in early 2026 to continue to progress.

a. Central Australia Mental Health and Alcohol and Other Drugs Service has commenced a review of organisational governance, current resourcing, personnel audit and service usage of child and adolescent mental health services across the Central Australia footprint. This also includes the Barkly Region within the governance structure.

Additionally, a Territory-wide infant child and adolescent mental health roadmap to system reform approach has been identified through consultation through 2024 and early 2025 of broacher system improvements to bolster service provision and collaboration.

b. As part of the review of service provision to children and young people. a focus on recruitment for services on Country and pathways for local Aboriginal employment pathways into mental health and wellbeing positions and career progression/advancement opportunities.

NT Health is also co-investing with the Commonwealth government the establishment of the Medicare Mental Health Kids Hub, which will lift access throughout the Central Australia region for children up to the age of 12 years.

NT Health continues to co-invest with the Commonwealth Government the enhancement of headspace services delivered by Central Australia Aboriginal Congress (CAAC) for young people from 12-25 years.

Actions NT Health will take:

NT Health will lead this work and initial planning is underway.

. An expert advisory group will be established for the Central Australia and Barkly regions, and this will be co-chaired by NT Health and CAAC.

Representatives of Education, Child and Family Services and the Australian Government will also be invited to participate.

. Child and Adolescent Mental Health Services are going to move to an NT-wide model of care to enable better distribution of resources and specialist expertise.

e NT Health is also co-investing with the Commonwealth Government the establishment of the Medicare Mental Health Kids Hub, which will lift access throughout the Central Australia region.

Recommendation 29 Actions NT Health has taken: Current situation:

. The Central Australian Regional Coordination Committee provides a mechanism for NTG Departments of Education, Children and Families and People Sport and Culture to work effectively together to ensure all settings are utilized to get supports to children who most need it.

. Current negotiations with the Australian government about the future provision of Foundational Supports reflect the need for therapeutic programs to address whole of community need, as there are very limited services and workforces available in remote communities.

Progress to date:

. Primary Health Care, Central Australia has completed 62% of ASQ TRAK checks within the last 6 months at Yuendumu.

. Increase in ASQ-TRAK training opportunities for NT Health staff has occurred in 2025 through collaboration with ACCHS and DET delivered ASQ-TRAK training sessions across the NT.

. Negotiations with the Commonwealth Government regarding the future provision of Thriving Kids (Foundational Supports for children 0-8 years).

A preferred model has been provided to the Commonwealth by NT Health that ensures improved service provision across remote. very remote and urban regions across the NT.

. The NT Aboriginal Health Forum has already prioritized this area of activity for tracking, and NT Health is currently developing dashboards to enable reporting.

Actions NT Heaith will take:

. NT Health will work with the NT Aboriginal Health Forum to enhance a more joined up engagement with Commonwealth agencies and funders and ACCHOs, noting that NT Health only provides 53% of primary health care in Central Australia region.

Recommendation 30 Actions NT Health has taken: Current situation:

° This strategy is supported and will be led by the Central Australian Regional Executive Director and supported by the Aboriginal Health Engagement and Workforce Division.

. Health Centre manager attends Yuendumu Community Safety meetings convened by NT Police.

. All staff attend mandatory Cultural Awareness training.

° Primary Health Care (PHC), Central Australia Community Engagement officer regularly visits and engages with the Yuendumu community.

Progress to date:

. PHC has scheduled 4 Local Health Advisory Group (LHAG) meetings in 2025 with engagement from the local community.

° PHC has informed Central Desert Regional Council (CDRC) of the challenges engaging with the community requested support to attend the Yuendumu Local Authority meeting to discuss the establishment of a LHAG, scheduled for 2026.

Recommendation 31 Actions NT Health has taken: Current situation:

b. The Remote Worker Safety Policy provides a whole-of-government approach to managing events in remote communities that pose risks to staff safety.

Itensures staff protection and continuity of government services.

Key responsibilities include:

. Regional Coordination Committees (RCCs), led by the Department of the Chief Minister and Cabinet, prepare, implement, and monitor Remote Worker Safety Plans for each region.

. NT Health, as an RCC member. communicaies its internal policies on temporary staff withdrawal through the Local Health Advisory Group.

Progress to date:

a.

In line with the Recommendation the guideline was updated and published on the NTH intranet policy centre in April 2023. This is a guideline for all communities to be used by NT Health staff, referencing the connection with Regional Coordination decision-making process for whole of NTG.

Recommendation 32

Actions NT Health has taken:

Current situation:

a & b. The NT Health Regional Executive Director for Central Australia, as a member

of the Regional Coordination Committee, is responsible for ensuring that NT Health contact details remain accurate and up to date for all committees and forums established to manage staff safety risks in remote communities.

NT Health present its Temporary Withdrawal Guidelines to the Regional Coordination Committee for awareness and to support coordination.

Action NT Health will take:

b.

Attendance at local community meetings will be captured in a file note by the Clinic Manager and saved in the approved NTG records management system.

These records will also be made available to the Regional Executive Director who can review and escalate matters to the Regional Coordination Committee as required.

Recommendation 33

Actions NT Heath has taken

Current situation:

There is extensive work already underway in NT Health to increase Aboriginal employment, and to enhance pathways for Aboriginal Health Practitioners.

More details on specific programms and outcomes can be reported regularly as required.’

| am satisfied that the CEO of CM&C, DoH and the Commissioner of Police, have considered the recommendations of the Territory Coroner and have responded to the recommendations.

DATE:

27 FEB 2026

MARIE-CLARE BOOTHBY