On 4 August 2014, three hours after doctors had stopped trying to revive Ms Dhu, Western Australian police sent out a press release.
“About 12.30pm today,” it read, “a 22-year-old woman being held in police custody at the South Hedland police station was taken to the Hedland Health Campus after alerting officers to the fact she was not feeling well. Upon arrival at the hospital the woman’s condition deteriorated and she passed away.”
A second statement followed two days later. The woman had been held in “lawful custody” since 2 August, it said. She had twice advised police of feeling unwell and been taken to hospital on “two separate occasions”. On both occasions police had been given certificates declaring she was medically fit to be held in custody.
Shortly after receiving the second statement, this reporter received a call from the head of the police media unit who wanted to stress that police had done the right thing. They had taken her to hospital – twice – and been told she was fine. This was very distressing for police officers, he said. What more could they do but trust the doctors?
Two years later, at a coronial inquest into her death, 16 police officers and one assistant commissioner repeated that argument in front of the shaking heads of Dhu’s family, holding up the medical certificates like a protective shield.
On Friday Dhu’s family will return to the coroner’s court in Perth to hear the state coroner Ros Fogliani’s findings on the four-week inquest.
The Yamatji woman, whose full name is not used for cultural reasons, had gone into septic shock four hours before she left the police station. Her heart had already stopped by the time two police officers, who told the triage nurse she was “faking it”, had wheeled her up to the emergency room window.
Clearly, at some point, she had become very ill. But in the inquest, every police officer returned to the medical certificates. Dhu had been declared fit to hold in custody, they said, so of course they thought her worsening symptoms were exaggerated.
She could not have been in an unbearable amount of pain for two days, because otherwise she would not have been declared fit. She could not have lost all feeling in her legs and the ability to stand up, could not have slipped into a semiconscious state and certainly could not have died before she even reached the emergency room.
Faced with a choice between a piece of paper and a young, crying Indigenous woman, officer after officer decided it was more likely the latter was “faking it” than the piece of paper was incorrect or even just out of date.
Dhu spent her final 44 hours surrounded by people who thought she was lying, wedged in a cell between a partner who was abusive and a stranger whose only connection to her was the shared colour of their skin. CCTV footage of Dhu in custody shows her deterioration, culminating in her being handcuffed and dragged from a cell, before being lifted by her hands and feet and carried to the back of a police van, just an hour before she was declared dead. It is harrowing vision that shows a woman who is clearly unwell being treated with at best a lack of urgency and at worst contempt.
It has been a long wait for the coroner’s findings. The last witness gave evidence more than seven months ago. Dhu’s family want police officers charged and the justice system overhauled, but few observers expect either. They have also applied for the public release of CCTV footage of Dhu’s final hours that was shown to the inquest in the hope that, like the graphic footage of the 17-year-old Indigenous boy Dylan Voller hooded and tied to a chair in Darwin’s Don Dale detention centre, it will spur the public to demand change. The coroner will also rule on whether to release the footage on Friday.
At a hearing in September, Fogliani said she was concerned that to release the footage before her findings were handed down would divorce it from the necessary context, and said she was concerned Dhu’s family was unprepared for just how distressing it would be to see the images of their dying girl across newsstands, despite the family’s insistence they knew what they were doing.
Dhu’s uncle, Shaun Harris, thinks the footage will show that Dhu was treated with neglect in custody, despite that not being a line of investigation before the coroner.
“It has got to get out there,” Harris told Guardian Australia. “To hear her and to see her like that … how can they say that they didn’t think she was in pain, or that she was faking it, when any decent person could see it on the footage?”
Harris has led the public campaign to demand justice for his niece, travelling Australia to speak at rallies and gatherings and connecting with figures like Lex Wotton, the Palm Island man who became the figurehead of the uprising in response to the 2004 death in custody of Mulrunji Doomadgee, as well as members of the Black Lives Matter movement in the United States.
Dhu has become a symbol of the Aboriginal Lives Matter movement in Australia, the most notorious Indigenous death in custody since Warburton man Mr Ward was cooked alive in the back of an un-airconditioned prison transport van in the Western Australian desert in 2008.
The protests began with a march in Perth in October 2014 which culminated in Dhu’s mother, Della Roe, confronting Western Australia premier Colin Barnett on the steps of parliament house and securing a commitment that he would endeavour to reduce Aboriginal incarceration rates.
Low-quality black and white images of her face have been printed on to placards and marched through the centre of Melbourne, and details of her last hours were shouted through a megaphone at a Black Lives Matter protest in Jackson Heights, New York.
‘Can you help me? It’s hurting like hell’
The story of Dhu’s death began years earlier when, as a minor, she received the first of seven minor offences for which she was ordered to pay a court fine. One was an offensive language charge for swearing at a police officer on the streets of Port Hedland.
The fines came to $3,622. Dhu, who was reliant on welfare, did not pay, prompting the court to issue a warrant of commitment to hold her in custody for four days until she had “cut out” her debt.
About 800 people are jailed solely for fine default in WA every year, according to a report by the inspector of custodial services, Neil Morgan, with an average stay of 4.5 days. It is an expensive practice: the cost of housing a prisoner for such a short period of time is about $770 a day, twice the average daily cost for a longer-term prisoner.
That warrant rested dormant in the system until police received a tip on 2 August 2014 that Dhu was staying at a house in South Hedland.
The tip had not been intended for Dhu. It had been made by one of her family members to report that her partner, Deon Ruffin, was breaching the conditions of a family violence restraining order relating to another woman by being in Hedland.
But when police went to collect Ruffin, they collected Dhu too. Both were put in cells attached to the police station, on the grounds that a transfer to Roebourne regional prison was too difficult to arrange. The next scheduled transfer to Roebourne was on Tuesday 5 August, the day Ruffin was scheduled to face court and Dhu was scheduled to be released. WA police do not keep data on the number of people held in police lockups for the sole purpose of fine default, despite it being a common practice in remote areas.
Ruffin and Dhu had met in Geraldton, a coastal town about 1,100km south of Port Hedland and 400km north of Perth, where Dhu lived with her grandmother, Carol Roe. He was almost twice her age and easily twice her size.
On 21 April that year, Ruffin had taken Dhu to the emergency room of the Geraldton hospital to get treatment for cracked ribs. She told doctors she had slipped on some rocks and was discharged, after an x-ray, with a diagnosis of a bruised chest wall.
That wasn’t true, Ruffin later told the inquest. Dhu didn’t fall, they had been “wrestling” and her ribs had had been injured in a “tussle”, after she had stabbed him in the leg with a pair of scissors.
“I was on my knees with [Dhu] behind me, had me in a headlock. And the place where we were staying ... the bloke was cleaning the house, and he had all these ornaments out in the living room, CDs, DVDs, in stacks,” Ruffin told the inquest.
“[Dhu] was behind me and I grabbed her from her jumper and pulled her over and she broke her rib on one of the ornaments.”
Dhu left Geraldton to escape Ruffin but he followed, catching up to her at the address where she was later arrested. Before he arrived, she had visited her father, Robert Dhu, who lives in the mining town.
“She said that her man was flogging her and he done the broken ribs,” he told the inquest.
When first class constables Vicki Eastman and Callan George went to collect Ruffin and Dhu at 5pm on 2 August 2014, they found Ruffin aggressive and Dhu polite. She was slow getting to the van, because she had a limp, and found it difficult to climb into the high capsule that serves as secure transport on police four-wheel-drives.
The first CCTV footage of her at the station, accompanying George along the corridor from the sally port to the charge room, shows her walking with a pronounced limp, her body hunched to the right.
When George asked what was wrong, she told him that she had broken ribs and had already seen a doctor. He did not ask how her ribs were broken.
Three hours later Dhu was back in the charge room crying in pain to Constable Carrie Sharples, after the latter decided Dhu was too distressed to remain in her cell.
“She said, ‘Miss, I am in a lot of pain’,” Sharples said.
Their conversation was captured on CCTV and played in the inquest. Dhu was wailing. Between her moans, a few sobbed lines of conversation could be heard.
Dhu said: “Can you help me?” And: “It’s hurting like hell.”
Sharples asked Dhu to rate her pain out of 10. Dhu said: “10.”
Dhu told Sharples she had broken her ribs in a fall, but told Sharples’ supervisor, Sergeant Ronald Patchett, that she had been “bashed”.
He did not investigate further. “I just knew in my mind it’s not going to be feasible to deal with it at that time because they are going to hospital, they needed to go to hospital,” Patchett told the inquest. “For me to sit down with her, it would be three to four hours … it wasn’t going to happen, she needed to go to hospital.”
Ruffin has not been charged with any violence against Dhu and has spent the two years since her death in jail for an assault against a former partner.
‘How can you fake dying?’
Peter Quinlan, senior counsel for the Aboriginal Legal Service of WA, who were acting for Carol and Della Roe, suggested that if police had approached Dhu as a victim of domestic violence it may have affected their treatment in custody. It may have prompted them to tell the hospital, which could have influenced their examination and caused them to find the golfball-sized lump of pus that was growing around that three-month-old cracked rib, the root of the sepsis that would later kill her.
Instead she was returned to the police lockup with a certificate declaring her medically fit to be held in custody and a note from the emergency room doctor ascribing her symptoms to “behavioural gain”.
Hedland Health Campus is exactly 1km from South Hedland police station. Both were built during the mining boom of the late 2000s to help the small town cope with the influx of fly-in fly-out workers.
Because of a complicated system of one-way streets and slip lanes, the drive between the two takes almost five minutes.
On that first night, Dhu was seen by Dr Annie Lang, who described her as “agitated” with “lots of swearing.”
Lang told the inquest she thought Dhu’s limp was “a little bit artificial”, like a child playing up their symptoms to get a parent’s attention, and found the way she was hunched over “inconsistent” with broken ribs.
Her brief notes mention musculoskeletal pain and “behavioural gain.”
“When I wrote those notes she was so well that I really didn’t place appropriate importance ... I had absolutely no idea that she was as sick as she was,” she told the inquest.
Lang prescribed endone, an opiate-level painkiller, and diazepam, because police had told her Dhu had become anxious when told she would have to spend the night in custody.
Back at the police station, “behavioural gain” had become “faking it”.
Dhu had also told the nurse she had taken a half a point (less than 0.1g) of methamphetamine the night before, which had become folded into the station’s collective theorising.
By the time Sergeant Rick Bond agreed to send Dhu to hospital for a second time at 5pm on 3 August 2014, it had become the dominant thread.
Bond had been on the phone to Robert Dhu and been speaking to Deon Ruffin, and had told both that Dhu was a hardcore user of methamphetamine and untold other drugs.
He was confident that her symptoms, which had worsened in 18 hours from pain in her chest to pains all over her body, could be attributed to drug withdrawal.
That view was cemented when he heard the report from Dhu’s second trip to hospital.
The triage nurse, Alyce Hetherington, told the escorting police officers that “this could be withdrawal from drugs”, after noting symptoms of an elevated heart rate, dehydration and anxiety.
Heatherington said Dhu did not have a fever, which emergency medicine specialist Dr Stephen Dunjey said might have indicated the drug withdrawal theory was incorrect and prompted doctors to discover the growing infection in her ribs and associated staphylococcal septicemia, but that can’t be verified.
Neither Heatherington, nor ward nurse Gitte Hall, nor Dr Vafa Naderi took Dhu’s temperature, with each telling the inquest it was not their responsibility.
Naderi said it was a “significant failure” not to take her temperature but told the inquest there were no symptoms of a chest infection or staphylococcal septicemia to detect, telling Dhu’s family: “I wish I was able to pick up on any abnormal signs that may have made a difference.”
Like Lang, he said his diagnosis was of general muscle pain, but his notes said “behavioural issues” and “drugs?”
By the morning of Monday 4 August, two things had happened. The first was that Dhu’s septicemia had progressed past the point of no return. Antibiotics, which pathologist Jodi White told the inquest could have saved her if administered on either of her first two hospital visits, would no longer be able to fight off the infection.
The second was that every police officer in the station, spurred on by Bond’s confident insistence, was sure Dhu was a drug addict who was faking her symptoms for attention.
Several, including Bond, told the inquest they did not believe it when they heard she had died, prompting an outraged response from Della Roe.
“They said she was faking it – how can you fake dying?” she told a rally outside court. “She wasn’t exaggerating, the poor girl was dying.”
The accounts of that morning from the police officers who came into contact with Dhu describe a person who is perfectly well and an apparently excellent actor, whose health takes a sudden and dramatic nosedive upon her third visit to the hospital.
The CCTV shows a different picture. Dhu can be seen throwing up into a cup in the early hours of Sunday. She asked to go to hospital at 7am. A short time later, she appears to lose the ability to stand up. She tries to sit up and falls back several times.
A third fall, which happened when senior constable Shelly Burgess yanked Dhu up by one arm off the mattress and then dropped her, causing her head to smack on the concrete fall of the cell, appears to trigger the final visit to hospital.
The footage does not have sound but, in the public gallery of the courtroom, people flinched at the silent thud, then looked away. The autopsy did not find any injury to the back of Dhu’s head.
Burgess then called Bond to help her lift the prone woman, and said she heard Bond whisper in Dhu’s ear: “You are a fucking junkie … you will fucking sit this out. We will take you to hospital but you are faking it.”
CCTV shows Bond bending over Dhu, but there is no sound recording from the cells. Aboriginal liaison officer Sophie Edwards, watching from the doorway, said Bond spoke “roughly” to Dhu but she didn’t catch what he said.
Bond denied making the comments, saying: “I didn’t think she was faking it, I didn’t know that it was that serious, I wasn’t aware.”
Twenty minutes later, at 12.33pm, constable Chris Matier appeared on the footage from the cell and places Dhu in handcuffs, before lifting her under the armpits and dragging her out of the cell. The footage cuts to the corridor and he is joined by Burgess, who picks up Dhu’s feet. Together they carry her limp form to the sally port, the handcuffs doing nothing but keeping her hands from dragging along the ground.
When the footage was played on the first day of the inquest in November 2015, Uncle Ben Taylor, a Noongar elder who has sat through countless inquests into the deaths of his people, muttered that she was being dragged “like a dead kangaroo”.
It’s a potent image in the history of black deaths in custody in Western Australia, linked back to the 1983 death of John Pat which sparked the royal commission.
Taylor is in his 70s and hard of hearing, so his whispers carry. Dhu was being treated, “like a dog”, he said, “like an animal”.
Eventually, heeding Fogliani’s warning that members of the public gallery must stay silent, he left when the footage was played. Court protocol must be respected. Those who remained, like Della Roe, lived their distress quietly, rocking gently on the plastic chairs.
At 12.45pm, the footage showed the police van arriving at the hospital. Burgess parked in the ambulance bay and Matier walked inside, reappearing a minute later with a wheelchair. Dhu is lifted out of the police van and placed in the wheelchair, her head snapping back.
Della Roe, watching the footage from the front row of the public gallery at the inquest, looked away.
“She’s dead,” she said.
A foot was dragged along the ground until Matier notices and lifts it back on to the footrest. There is no sound on the video from inside the waiting room, but Caroline Jones, the triage nurse, filled in the dialogue.
“They were going, ‘OK, she is just putting it on, she is faking it’,” she told the inquest.
Jones said she told police Dhu was in cardiac arrest, and rushed her through to a resuscitation bay. By the time her death was called at 1.38pm, officers from internal affairs were already on a flight up from Perth.
Their response, at the end of their investigation, was to send 11 police officers a letter warning they had failed to comply with standard operating procedure, largely for failing to write notes in the station’s custody log. Two have since received a promotion.
No one was disciplined for failing to recognise the severity of Dhu’s illness, but they have redesigned the certificate of medical fitness to be held in custody to make it clear to police there is a gulf between “fit to be held in custody”, which just means the person does not need to be hospitalised immediately, and “100% healthy”.
Assistant commissioner Duane Bell told the inquest that after watching the CCTV footage: “I see the objective signs that Ms Dhu needed early medical attention.”
Since Dhu’s death, six more Indigenous people have died in custody in WA, the latest on Saturday.
Carol Roe believes Barnett has broken his promise to her and her granddaughter, who is now buried in the cemetery across the road from her house. She is exhausted from two-and-a-half years of fighting. Her health is failing.
If Fogliani’s findings are anything less than a damning criticism of how Dhu was treated, accompanied by the release of the footage, she will be devastated.
“They don’t care because it’s an Aboriginal kid dead,” she said. “All they’re saying is ‘don’t recall, don’t recall’... that’s why we’ve got to stand together and push together and keep putting our story out there.
“Everyone has got to see how my granddaughter was being treated.”
