Australia’s shame: how we mapped a decade of Indigenous deaths in custody

Over the course of several months, a team at Guardian Australia built the Deaths Inside project, which collated all available data to build a definitive, searchable database cataloguing the 147 Aboriginal and Torres Strait Islander people who died in custody between 2008 and 2018. Many died from treatable medical conditions, and more than half had not been convicted of a crime. In response to the systemic failures exposed by this investigation, Aboriginal leaders have called for an immediate review of the “absolutely unacceptable” numbers of Indigenous deaths in custody, and are demanding Australia develop an independent system for monitoring them as a priority.

The project was speerheaded by Lorena Allam, the Guardian’s Indigenous affairs editor, in close collaboration with Nick Evershed, the data and interactives editor for Guardian Australia and Calla Wahlquist, one of Guardian Australia’s reporters.

“When the coronial inquest into the death of a Yamatji woman, known as Ms Dhu, began in November 2015, we decided it would be helpful, for context, to put a line in our coverage explaining how many Aboriginal and Torres Strait Islander people had died in custody since the royal commission into Aboriginal deaths in custody produced its final report in April 1991.

“Miss Dhu, who was 22 when she died in police custody in Port Hedland on 4 August 2014, was born six months after that final report was published. She had been jailed for unpaid fines, a practice the royal commission recommended be abolished. How many had died between the publication date and her birth? How many more had died between her death and the opening of the inquest? We assumed there would be a list. There was not.

“During the time I was covering the inquest I began emailing every police and corrective services department in Australia to learn how many Indigenous people had died in custody since the publication of the most recent Australian Institute of Criminology report on deaths in custody, which at that stage only covered until July 2013.

“I also had a chance to speak to some leading deaths-in-custody campaigners, who were in the courtroom alongside me. None of them knew of a national register that individually listed every Aboriginal and Torres Strait Islander person who had died in custody and set out the circumstances surrounding their death, but all said they wanted that resource. A few had plans to develop it but had run out of resources – the research task is immense and never-ending if you intend to keep updating the list.

“Together with those contacts, I pulled together a list of all deaths in custody that we were aware of, and that list became the basis for Deaths Inside.

“A key problem was that corrections departments had stopped issuing media releases following a death in custody, and instead only confirmed the details of a death when asked. That meant that, unless a family member had contacted either the media or an advocacy group, many deaths went unmarked until the official figures came out. That, coupled with the extreme delay between death and inquest in Western Australia – we found an average of 2.5 years until the start of the inquest, and another three months for the findings – meant that the public perception of the issue was limited to those few high-profile cases that captured media attention.”

“It was a bigger task than we had anticipated. We originally wanted to record every Indigenous death in custody since the royal commission ended in 1991, but we soon realised that was beyond our capacity, partly because of the volume of work involved but mainly because official monitoring had fallen away. That in itself underscored the need for our investigation: so many statistics were out of date, or not even collected.

“So, we looked at the past 10 years of coronial data, from 2008-2018. To do that, we had to compile coronial findings from every Australian jurisdiction as well as track media reports or press releases from custodial agencies.

“We read, checked and recorded every coronial finding relating to an Indigenous death in custody from 2008 onwards, as well as cases that are still awaiting inquest. For 2010-2015, we also collected information on every single death in custody in order to have a large enough sample size to produce meaningful analysis.

“We examined 463 cases, 147 of which concerned an Indigenous person. We have determined that in the 30 years since the royal commission there have been more than 407 Indigenous deaths in custody.

“We checked each case against a number of data points, such as age, gender, whether a person was on remand or sentenced, the kind of charges they faced, whether they had health or mental health issues and whether these were managed or even acknowledged, whether force was used by authorities and whether police and prisons followed their own procedures. This last criterion was important because the royal commission handed down many recommendations to improve custodial procedures more than 30 years ago.

“The most important thing we did was work with families, their legal representatives and others – NGOs, criminologists – to make sure our work was carried out sensitively, that our access and sharing of the information was done with the full permission and support of bereaved families, and was presented in a way that did not exacerbate trauma for anyone who chose to click through to the database.

“So many of the families we worked with were so generous with their time and support. They continue to advocate for their loved ones in the face of institutional neglect and indifference. The old saying is ‘justice delayed is justice denied’, and I think that holds true for many of the people we met while doing this project.”

Evershed faced the challenge of making the data make sense

“In some ways our analysis cemented what people familiar with the deaths in custody either knew or suspected, but seeing the stark difference in treatment between Indigenous and non-Indigenous people was still shocking.

“We showed that Indigenous people were dying in custody of preventable conditions, and they were less likely than non-Indigenous people to get all the medical care they needed. Official procedures were less likely to be followed in cases involving Indigenous people. Mental health or cognitive impairment was a factor in many cases.

“One of the biggest challenges came in how we presented these results. All too often data analysis and visualisation can result in distancing the reader from the people underlying the statistics. We wanted to address this with a design that would present the results of our investigation in a way that would communicate the broader trends while still preserving the humanity of the people involved.

“We built on top of our previous work on visual databases to try to incorporate more human elements to the design, hopefully providing a reminder that each case represents a human life.”

Wahlquist explains the impact the project had in Australia

“We expected that the project would be picked up by advocates and by family members who would be able to use the database to find common themes within cases and to find precedents for what had happened to their loved ones. From day one, we heard from families, community advocacy groups and academics about how they intended to make use of the resource.

“But we also heard from lawyers, including the heads of Aboriginal legal services around the country, who said they planned to use the database to build cases for coronial inquests, find examples of recommendations that had been made when similar deaths occurred in other jurisdictions, and also provide evidence of the scale of the problem.

“One of the challenges that lawyers in death-in-custody inquests often face is getting the court to tackle the systemic issues when the institutions responsible insist it is an isolated case. The Deaths Inside database dismantles that myth.

“The significance of the project was recognised at the Walkley awards in 2018, where it won the award for innovation and was a finalist in Indigenous Affairs. It was also commended in a motion that passed the Australian Senate in September.”