Revealing racism in policing through coronial inquest processes

Abstract

Set against the backdrop of ongoing Aboriginal and Torres Strait Islander deaths in custody, this article examines how racism in policing can be revealed through coronial inquest processes. This article provides an in-depth examination of the attempts to do this in two coronial inquests – one being the coronial inquest into the death of Yorta Yorta woman Aunty Tanya Day; the other, the coronial inquest into the death of Warlpiri and Luritja teenager Kumanjayi Walker. This article sets out the significant findings, or lack of findings, of racism made in each inquest, while also highlighting the limitations of the current system. The article also calls for governments to reckon with racism in policing and take action to prevent future Indigenous deaths in custody.

Warning: Aboriginal and Torres Strait Islander readers are warned that the following article contains the names of deceased persons.

Over 600 Aboriginal and Torres Strait Islander people have died in custody ¹ since the Royal Commission into Aboriginal Deaths in Custody (the Royal Commission) handed down its final report in 1991. ² The Royal Commission examined the deaths of 99 Aboriginal and Torres Strait Islander people who had died in custody, finding that more First Nations people were likely to die in custody because they were ‘grossly over-represented’. ³ The Royal Commission was largely critical of the investigations into the deaths in custody it examined, identifying that in ‘very few cases … was the investigation into the death other than perfunctory and from a narrow focus’. ⁴ This led to the Royal Commission recommending that ‘all deaths in custody be required by law to be the subject of a coronial inquiry’. ⁵ Laws now exist in each jurisdiction for mandatory coronial inquests into all deaths in custody, ⁶ although deaths because of apparent ‘natural causes’ can be an exception to this in some jurisdictions. ⁷ Despite increased scrutiny of deaths in custody, governments have allowed Aboriginal and Torres Strait Islander deaths in custody to continue, with the country experiencing a mass imprisonment crisis – in 2024–25, the largest number of Indigenous deaths in custody were recorded since the National Deaths in Custody Program began monitoring the extent and nature of deaths in custody in 1979–80. ⁸

In a move led by the families left behind and Aboriginal legal services, coronial inquests have recently been used to try and reveal racism in policing. This article examines two of these cases – the inquest into the 2017 death of Aunty Tanya Day in Victoria, which was the first Australian inquest in which ‘systemic racism’ was explicitly included within its scope, and the inquest into the 2019 death of Kumanjayi Walker in the Northern Territory (NT), the first Australian inquest to find individual, institutional and structural racism in policing. ⁹ This article draws on publicly available information from each inquest with a view to helping other families of those who die in police custody and those families’ lawyers reveal racism in any future inquests, alongside calling for governments to reckon with racism in policing and take action to prevent deaths in custody in the first place.

These inquests were not the first to consider racism in relation to deaths in police custody. In 2014, 22-year-old Yamatji woman Ms Dhu died in police custody in Western Australia after being arrested for unpaid fines. Ms Dhu died of a severe infection and pneumonia, stemming from a broken rib sustained as result of family violence, prior to being detained in custody. ¹⁰ Following her arrest Ms Dhu was, however, mocked and dismissed by police. ¹¹ In the inquest findings delivered by Coroner Ros Fogliani, the relevant police officers implicated in Ms Dhu’s death were found not to have been ‘motivated by conscious deliberations of racism’. ¹² The Coroner did, however, go on to state that

it would be naïve to deny the existence of societal patterns that lead to assumptions being formed in relation to Aboriginal persons … until there is a seismic shift in the understanding that is extended towards the plight of Aboriginal persons, the risk of unfounded assumptions being made without conscious deliberation continues, with the attendant risk of errors. ¹³

At the outset, it is critical to note that the task of revealing racism through coronial inquest processes must be specific to the facts of the particular case, sufficiently connected with the applicable death and should not constitute a wide-ranging inquiry or a ‘roving Royal Commission’. ¹⁴ It is also important to note that the applicable standard of proof in the coronial jurisdiction is the ‘balance of probabilities’, with the ‘Briginshaw qualification’ that the

seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues proved to the reasonable satisfaction of the tribunal. ¹⁵

The use of this qualification is, however, not without criticism in inquests. As outlined by Aunty Tanya Day’s children – Belinda, Warren, Apryl and Kimberly Day (the Day family) – in their final submissions to the coronial inquest into their mother’s death, such an approach risks ‘prioritising the protection of police officers’ reputations over finding the truth’. ¹⁶ This is particularly the case in circumstances where the consequences flowing from a potential finding of racism do not just impact the police officers involved, but can also have considerable impacts on the family of the loved one who died in custody.

Coronial inquest into the death of Aunty Tanya Day

Aunty Tanya Day was a proud Yorta Yorta woman and a much-loved mother, grandmother, sister and community advocate. Aunty Tanya died on 22 December 2017 after sustaining a serious head injury in a police cell 17 days earlier. During a train journey on 5 December 2017, Aunty Tanya was approached by a V/Line train conductor, Mr Shaun Irvine. He set off a series of events that culminated in Aunty Tanya being ejected from the train, being arrested by Victoria Police officers for being ‘drunk in a public place’ and being detained in a police cell at the Castlemaine police station. Despite Victoria Police’s own policy requiring that she be physically checked by police every 30 minutes, this did not happen. The CCTV footage showed Aunty Tanya fall a number of times, including a significant fall at around 4:50pm where she hit her head on the concrete wall of the police cell. When a physical check finally took place at 8:03pm, police noticed a bruise on Aunty Tanya’s forehead. An ambulance was called and she was taken by paramedics from Ambulance Victoria to Bendigo Hospital. ¹⁷ Aunty Tanya was transferred to St Vincent’s Hospital in Naarm (Melbourne) where she subsequently died. Aunty Tanya was the second member of her family to die in police custody. Her uncle, Harrison Day, died in police custody in 1982 after he was arrested for unpaid fines, issued earlier for being ‘drunk and disorderly’. His death was investigated by the Royal Commission. ¹⁸

Decriminalisation of public drunkenness

On 6 December 2018, at the first directions hearing, Deputy State Coroner Caitlin English took the unusual step of foreshadowing that she would be making a recommendation that the crime of public drunkenness be abolished. ¹⁹ In the week before the inquest commenced, the Victorian government announced that it would abolish the offence. ²⁰ In her findings, the Coroner outlined that the law which criminalised public drunkenness was an example of one which ‘operates to the disadvantage of Aboriginal people hence the [Royal Commission’s] recommendation.’ ²¹ Testament to the tireless and ongoing advocacy of the Day family in seeking justice for their mother, alongside extensive grassroots campaigning efforts, decriminalisation came into effect on 7 November 2023. ²²

Scope of the inquest

As Aunty Tanya died as a result of an accident or injury and was a person detained in custody immediately before her death, a coronial inquest was mandatory. ²³ On 30 April 2019, the Coroner heard submissions from the Day family and interested parties regarding the scope of the inquest, and whether it should include ‘systemic racism’. From the outset, the Day family were clear that they believed racism played a role in their mother’s death. The Day family pointed to the different treatment experienced by Aunty Tanya, notably that she ‘was arrested whilst drunk in a public place and she was treated differently than a white woman would have been treated.’ ²⁴ The Day family, through their Counsel, put four reasons supporting the relevance of systemic racism to the inquest, being

the evidence of those people whom it directly affects, the Royal Commission into Aboriginal Deaths in custody and numerous other studies supports its existence, the data outcomes which prove disproportional outcomes and fourthly, human nature. ²⁵

The Day family urged the Coroner to use systemic racism as a relevant ‘lens’, or for her Honour to put on a different pair of ‘glasses’, to assess the evidence to see whether it was a cause of Aunty Tanya’s death. ²⁶ The Day family highlighted examples of how they saw racism contribute to their mother’s death, including the decision by police to arrest her rather than arrange a medical assessment, and the failure of police to follow their own procedures and afford Aunty Tanya appropriate medical care while locked away in custody, which were ‘wholly consistent with disproportionate outcomes that can only be explained by systemic racism, unless another non-discriminatory causal factor can be identified.’ ²⁷

This was supported by data which showed that Aboriginal women in Victoria were 10 times more likely to be targeted by police for public drunkenness compared to non-Indigenous women at the time of Aunty Tanya’s arrest. ²⁸ The Coroner stated that ‘[s]tatistical data whilst suggestive, is not evidence of causation’ ²⁹ and rejected the inductive reasoning that ‘because Aboriginal people are overrepresented in public order offences, as a result of systemic racism, Ms Day was necessarily charged with a public drunk offence because of systemic racism.’ ³⁰ Her Honour went on to say, however, that the data ‘provides a reasonable basis for [her] to assess whether direct or indirect racism played a role in determining the facts comprising the circumstances of Ms Day’s death.’ ³¹

The Day family’s submissions on scope were supported by an expert report, which canvassed the data and literature on racism in the criminal legal system and applied this to Aunty Tanya’s case. ³² The Coroner accepted that the report provided a ‘contextual framework’ and formed ‘part of the material through which decisions and policies connected with Ms Day’s death can be critically appraised’ but added that she would be making her own assessment of the evidence. ³³

The Day family also submitted that Aunty Tanya’s human rights were engaged pursuant to the Charter of Human Rights and Responsibilities Act 2006 (Vic) (the Charter). ³⁴ The Victorian Equal Opportunity and Human Rights Commission (VEOHRC) intervened and supported this. ³⁵ The inclusion of systemic racism within scope was opposed by Victoria Police and Ambulance Victoria. ³⁶ V/Line supported consideration of whether discrimination contributed to the death, so long as it was ‘viewed entirely through the circumstances of the case.’ ³⁷

On 25 June 2019, the Coroner ruled that she would ‘consider the action and behaviour by the various people who interacted with Ms Day … and whether her indigenous heritage played a role in that treatment.’ ³⁸ The explicit inclusion of ‘[w]hether racism, systemic or otherwise, was a factor in the cause or circumstances of Ms Day’s death’ ³⁹ within the scope of the inquest was an Australian first.

The inquest

The Day family were represented in the inquest, and VEOHRC intervened. Key agencies – notably V/Line, Victoria Police and Ambulance Victoria – were also represented.

The Coroner allowed ‘witnesses to be questioned as to whether racism played a part of their decision making, including Ms Day’s treatment, options considered, their motivations and potential unintended effects of their decision making.’ ⁴⁰ The cross-examination explored the potential operation of unconscious bias against Aboriginal people in decision-making, with a particular focus on the exercise of discretion. ⁴¹ While ‘no witnesses admitted to holding racist beliefs’ and ‘denied Ms Day’s Aboriginality played a role in their actions or decision making’, ⁴² the

[c]ross examination endeavoured to elicit points of difference in the treatment of Ms Day by comparing how the witness would act in the hypothetical scenario involving a middle-aged white woman in a similar situation to Ms Day. ⁴³

The Day family’s final submissions implored the Coroner to make findings about systemic racism on the basis that it played a central role in their mother’s death. ⁴⁴ On this, they said:

Systemic racism is so dangerous exactly because it is completely usual, and therefore hard to see for those who are not affected by it. … ‘Usual’ pre-emptively denies that anything needs to change. We ask you to look beyond what is ‘usual’, and to look for the truth. ⁴⁵

Inquest findings

On 9 April 2020, Coroner English found that ‘Ms Day’s death was clearly preventable had she not been arrested and taken into custody.’ ⁴⁶

During her findings, the Coroner canvassed a handful of coronial cases that considered racial bias against Aboriginal and Torres Strait Islander people, including the inquest into the 2016 death of 27-year-old Wiradjuri woman, Naomi Williams, in New South Wales (NSW). ⁴⁷

Findings made in relation to the V/Line train conductor

The Coroner drew the inference that the rapid decision-making process of Mr Irvine, the V/Line train conductor who formed the view that Aunty Tanya was ‘unruly’, was influenced by his unconscious bias and her Aboriginality. ⁴⁸ Mr Irvine ‘was reluctant to own that his intent or preference was for Ms Day to be removed from the train’ ⁴⁹ which suggested that Aunty Tanya ‘may have been treated differently to other passengers’. ⁵⁰ This was in circumstances where Aunty Tanya was the first and only sleeping passenger Mr Irvine had asked for police assistance to remove (although he saw three sleeping passengers per week). ⁵¹

Findings made in relation to the arresting police officers

In contrast, the Coroner did not find that the decision by police to arrest Aunty Tanya was influenced by her Aboriginality. Her Honour found that once the arresting police officers formed the view it was unsafe to leave her sleeping on the train, arrest was the only viable option. ⁵² The Coroner did, however, note that the decision to take Aunty Tanya to the police station was not in accordance with relevant guidelines, given that her presentation should have required police to take her to hospital or seek urgent medical advice. ⁵³

The inquest also heard evidence about police being called to attend to a ‘heavily intoxicated’, non-Indigenous woman at a local hotel shortly after Aunty Tanya was taken into custody. The non-Indigenous woman was not arrested nor detained in a cell – she was given a lift home. The differential treatment afforded to this non-Indigenous woman was explained by the Coroner by ‘the fact that woman had an address in Castlemaine where she could be easily driven by the police officers.’ ⁵⁴ The Coroner found, in relation to Aunty Tanya’s case, that this counter-factual ‘reflected an absence of problem solving [by the police officers] and the genuine treatment of custody as a place of last resort, particularly for a minor offence’. ⁵⁵

As put by the Day family, ‘[t]he contrast is striking.’ ⁵⁶ While the Day family advocated that this presented an opportunity for the Coroner to find that Aunty Tanya was treated differently based on her race, her Honour did not think that there was sufficient evidence to make such a finding. ⁵⁷

Findings made in relation to the detaining police officers

The Coroner declined to make any findings in relation to racism on the part of the police officers responsible for detaining Aunty Tanya at the police station, instead characterising their actions as indicative of a ‘culture complacency regarding people who are drunk’. ⁵⁸ The Coroner found that: ‘[e]very instant of Ms Day’s behaviour in the cell was simply the stereotypical conduct of an intoxicated person.’ ⁵⁹ The Coroner found this approach ‘illustrates the power of stereotype and its resistance to correction.’ ⁶⁰

The checks conducted on Aunty Tanya while she was detained were inadequate and the Coroner found that neither police officer responsible for Aunty Tanya’s detention – being Sergeant Edwina Neale and Leading Senior Constable Danny Wolters – ‘took proper care of Ms Day’s safety, security, health and welfare’. ⁶¹ Had checks on Aunty Tanya been conducted in accordance with the relevant requirements, her deterioration may have been identified earlier. ⁶² The Coroner therefore found that Aunty Tanya was ‘not treated with humanity and respect for the inherent dignity of a human person as required by the Charter.’ ⁶³

While the Coroners Court cannot determine guilt, the Coroner directed that the Director of Public Prosecutions (DPP) be notified on the basis that the totality of the evidence supported a belief that an indictable offence may have been committed. ⁶⁴ In a decision that speaks volumes about a legal system that shields police from accountability, the DPP subsequently declined to prosecute. ⁶⁵ Victoria Police subsequently confirmed that Sergeant Neale and Leading Senior Constable Wolters escaped any serious disciplinary action for their involvement in Aunty Tanya’s death, with the latter ‘provided workplace guidance following a charge of duty failure.’ ⁶⁶

Flaws in police investigation

Despite significant concerns raised during the inquest by the Day family regarding the police’s flawed investigation into their mother’s death – describing it in their final submissions as ‘not independent or effective’ ⁶⁷ and asking for ‘a truly independent investigator for police contact deaths; not police investigating police’ ⁶⁸ – the Coroner did not accept that ‘there were deficiencies in the standard of the coronial investigation.’ ⁶⁹

Recommendations

The Coroner made ten recommendations, ⁷⁰ including the decriminalisation of public drunkenness, as foreshadowed at the outset of the inquest. Specifically in relation to policing, the Coroner recommended that Victoria Police review their manual to include a falls risk assessment for people in custody whose balance may be affected by alcohol, and implement training regarding the medical risks of people affected by alcohol and the mandatory requirements applicable for the safe management of persons in police custody. Recommendations were also made for Victoria Police to evaluate its training and education regarding the Royal Commission and request VEOHRC to conduct a review.

The extent to which these recommendations have achieved systemic change has, however, been limited. While the decriminalisation of public drunkenness in Victoria, without the enactment of a civil protective custody regime in its place, represents landmark reform, racist over-policing of Aboriginal and Torres Strait Islander people continues to be a systemic issue in Victoria. ⁷¹

Coronial inquest into the death of Kumanjayi Walker

Two years after the death of Aunty Tanya in Victoria, 19-year-old Kumanjayi Walker was killed in the NT after being shot three times at close range by NT Police officer, Zachary Rolfe. Kumanjayi Walker was a proud Warlpiri and Luritja teenager and a much-loved member of his family and the Yuendumu community.

Mr Rolfe was part of the Immediate Response Team deployed to Yuendumu from Mparntwe (Alice Springs) on 9 November 2019 after Kumanjayi Walker was involved in an incident with local police who attempted to arrest him. ⁷² This followed Kumanjayi Walker breaching a suspended sentence and leaving the Central Australian Aboriginal Alcohol Programs Unit to attend his grandfather’s funeral and participate in Malamala (Sorry Business). ⁷³ Mr Rolfe was charged with murder, but acquitted by a jury on 11 March 2022. Mr Rolfe was subsequently dismissed from NT Police in 2023 for ‘penning an open letter criticising the inquest and former police commissioner.’ ⁷⁴

The shooting of Kumanjayi Walker took place in circumstances where health services were withdrawn from Yuendumu on the morning of 9 November 2019. This meant there were no operational medical services in the community on the night Kumanjayi Walker was killed. ⁷⁵ While the North Australian Aboriginal Justice Agency (NAAJA) urged the Coroner to find that the decision by NT Health to withdraw health services was infected with racism, the Coroner declined to make such findings. ⁷⁶

Scope of the inquest

On 9 and 12 September 2022, Coroner Elisabeth Armitage heard submissions from Kumanjayi Walker’s family, as well as NAAJA and other interested parties regarding the scope of the inquest. This was prompted by objections made by Mr Rolfe to several ‘issues’ identified in an ‘issues list’ prepared by Counsel Assisting, as well as specific objections to certain categories of evidence.

As the ‘issues list’ generated a significant ‘level of disagreement’, ⁷⁷ the Coroner ultimately found it unnecessary and inappropriate to rule on ‘scope’. ⁷⁸ The Coroner, however, did overrule two specific objections to evidence made by Mr Rolfe, including in relation to his racist text messages. ⁷⁹ Mr Rolfe subsequently objected to further categories of evidence being received by the Coroner, which were also overruled. ⁸⁰ These objections included ‘evidence concerning the alleged discrimination by NT Police against indigenous persons or community police’. ⁸¹ On this, Mr Rolfe submitted that the inquiry should be confined to the immediate circumstances surrounding the death as shown in the body-worn footage. ⁸² In response, the Coroner noted that

the focus on the body-worn footage ‘ignores a range of decisions made by Constable Rolfe and others … which led to the confrontation with Kumanjayi, which may or may not have been affected by conscious or unconscious racial bias’. ⁸³

The Coroner went on to add that such ‘decisions may have increased the likelihood of Kumanjayi Walker’s death.’ ⁸⁴

NAAJA sought to tender an expert report entitled ‘In Normal Circumstances’: Understanding the Structural Nature of Racial Violence in the Northern Territory. ⁸⁵ NT Police, NT Health, the NT Police Association and Mr Rolfe objected. The Coroner did not receive the report in its entirely into evidence, ⁸⁶ although Part 3, which provided an explanation of ‘key concepts’ into evidence, was received. ⁸⁷ This followed NAAJA submitting that

concepts of institutional or systemic racism may provide a ‘lens’ through which to view the relevant conduct and decisions of the [NT Police], NT Health and their agents, and assist to ‘determine whether systemic racism is in fact present in this case’. ⁸⁸

The inquest

Kumanjayi Walker’s family – the Brown, Walker, Lane and Robertson families – were represented in the inquest, as were the Parumpurru Committee of Yuendumu. NAAJA intervened to highlight systemic injustices experienced by Aboriginal people in the NT. ⁸⁹ Key agencies – notably NT Police and NT Health – were represented. Mr Rolfe and other police officers were represented, and the NT Police Association also intervened.

The protracted inquest was delayed many times, primarily due to numerous unsuccessful attempts by Mr Rolfe to avoid giving evidence. Despite this, Mr Rolfe served as the main portal for much of the evidence about racism in policing being revealed during the inquest. ⁹⁰ While the existence of the mock ‘awards’ and their racist origins were initially denied by senior members of NT Police, subsequent evidence from Mr Rolfe and others confirmed their racist meaning. ⁹¹ There was also evidence of racist text message exchanges between Mr Rolfe and other police (including two sergeants) and Mr Rolfe’s use of force history, which were ruled inadmissible for his murder trial. ⁹²

In cross-examination, several police officers denied that racist text messages were indeed racist and attempted to minimise their actions. ⁹³ When police were cross examined about the link between racist language, dehumanisation and how that can inform police actions, some were reluctant to admit such a connection. ⁹⁴ The former Commissioner of NT Police, Michael Murphy, conceded, however, that racist attitudes are linked to behaviour: ‘your thoughts become your words, and your words become your actions, and your actions become your character, and your character becomes your destiny …’. ⁹⁵ He also accepted that racism in NT Police was not just historic but ‘recent’, and that previous denials of racism by him had effectively ‘gaslit’ members of the Aboriginal community who had experienced racism. ⁹⁶

Inquest findings

On 7 July 2025, Coroner Armitage found that Kumanjayi Walker’s death was ‘avoidable’ and a case of ‘officer induced jeopardy’. ⁹⁷

Findings made in relation to Mr Rolfe: Everyday racism

The Coroner found that Mr Rolfe ‘was racist, and that there is a risk that this racism affected his interactions with the community of Yuendumu on 9 November 2019 … in a way that increased the likelihood of a fatal outcome.’ ⁹⁸ While the Coroner did not find that Mr Rolfe ‘was motivated by racism’, she found that ‘his racist attitudes may have influenced (consciously or unconsciously) his failure to take adequate steps to minimise the risk of a fatal interaction, and his perception of the risk posed.’ ⁹⁹ That the Coroner could not exclude this was ‘a taint that may stain the NT Police.’ ¹⁰⁰

Turning to Mr Rolfe’s use of force history, the Coroner identified that Mr Rolfe had used unnecessary force on at least five occasions, that she had concerns about the use of force on a further two occasions, and that there were other instances where she was satisfied that the use of force was avoidable. ¹⁰¹ The Coroner went on to observe that ‘Mr Rolfe held and expressed racist views about Aboriginal people and that his use of force history, and telephone messages, demonstrated that he had dehumanised the Aboriginal population he was policing.’ ¹⁰² The Coroner explained this connection:

It may be that [Mr Rolfe’s] racist attitudes led to a dehumanising of suspects like Kumanjayi Walker. Faced with an opportunity (indeed, an obligation) to do everything possible to minimise the risk of injury, Mr Rolfe’s dehumanising of the target may have contributed to his failure to take an alternative, less risky path, and his willingness to rush in. ¹⁰³

Findings made in relation to NT Police: Not a case of one ‘bad apple’

The Coroner found that NT Police was ‘an organisation with significant hallmarks of institutional racism.’ ¹⁰⁴ While the Coroner found ‘many’ of the police who gave evidence to the inquest to be ‘curious and culturally sensitive’, her Honour also found that ‘racist language and actions were not confined to Mr Rolfe, and this was not a case of one “bad apple”.’ ¹⁰⁵ On this, the Coroner found that

structural and institutional racism permitted a work environment to exist which not only tolerated Mr Rolfe’s racism but allowed it to go unchecked and permitted others to actively engage in it with him. ¹⁰⁶

On the racist text messages, the Coroner noted they ‘were not aberrations, but were reflective of a work culture that tolerated, and, indeed, tacitly endorsed, racism.’ ¹⁰⁷ Further, on the ‘grotesque’ mock ‘awards’, ¹⁰⁸ the Coroner found the fact that ‘no police member, including no senior police, who knew of these awards reported them is clear evidence of entrenched systemic and structural racism within NT Police.’ ¹⁰⁹

Findings made in relation to NT Police: Culture of impunity

The Coroner identified that ‘institutional racism is likely to foster, or compound, more overt forms of interpersonal racism.’ ¹¹⁰ Citing Mr Rolfe’s use of force history as an example, the Coroner outlined that ‘NT Police had consistently failed to adequately investigate complaints alleging inappropriate or excessive use of force by Aboriginal complainants.’ ¹¹¹ The Coroner explained that a ‘feature of these inadequate investigations included a consistent, and uncritical, preference for the versions of NT Police officers over Aboriginal complainants.’ ¹¹² While the Coroner would not say whether that preference was the result of a racial bias, she did say that ‘its product was very likely to have been to create in an officer like Mr Rolfe a sense of impunity when using force against Aboriginal men’. ¹¹³

Recommendations

The Coroner made 33 recommendations. ¹¹⁴ Specifically in relation to policing, the Coroner recommended that NT Police engage with local leadership to develop an agreement setting out the circumstances when police could carry guns in community. Recommendations were also made for increased use of Aboriginal community police officers and improved police induction and training. A recommendation was also made for the ongoing development of an anti-racism strategy, which was subsequently launched on 7 November 2025. ¹¹⁵

The Coroner also recommended that NT Police ‘set up a working group … to develop and implement improved procedures for addressing complaints made by Aboriginal people about police use of force and/or allegations of racism’. ¹¹⁶ Despite the Coroner’s critique of Mr Rolfe’s actions and the failings of the current police complaints system, this recommendation fell short of long-standing calls to meaningfully hold police to account for misconduct by creating an independent police ombudsman. Following the findings being handed down, Kumanjayi Walker’s cousin and proud Warlpiri woman, Samara Fernandez-Brown, said:

To hear the Coroner identify structural and entrenched racism in the NT Police has made us feel validated. Our family and community have always felt that racism killed Kumanjayi. We are disappointed that recommendations fall short on holding the NT Police to account for racism, violence and deaths in custody. ¹¹⁷

Conclusion

Against the backdrop of ongoing Aboriginal and Torres Strait Islander deaths in custody, it is hard to understand why racism in policing – at any level that it might manifest – is not an issue that warrants consideration in all coronial inquest processes prompted by an Aboriginal and Torres Strait Islander death in custody.

The landmark findings delivered by the Coroner following the coronial inquest into the death of Kumanjayi Walker confirm what Aboriginal communities have been saying for years about the state of policing in the NT. The Coroner drawing links between racist attitudes, the dehumanisation of Aboriginal people, and how this can inform police actions is hugely significant in explaining how racism and policing can form a toxic combination resulting in deaths in custody. If Mr Rolfe had, however, successfully avoided giving evidence, much of the evidence regarding how rife racism is within NT Police would never have been revealed. Even then, revelations of racism being ‘normalised’ within NT Police were not enough to prompt the Coroner to recommend an independent police ombudsman.

While the coronial inquest into the death of Aunty Tanya prompted landmark reform in Victoria, the Day family were clear that racism in policing played a role in their mother’s death and yet this was not recognised in the findings made in that inquest.

This article has traced the trajectory of these two coronial inquests with the aim of highlighting how racism in policing can be revealed through such processes, while also shining a light on the limitations of the current system.

Ultimately, it should not be left to the families of people who die in custody to fight for justice. To end Aboriginal and Torres Strait Islander deaths in custody, governments across the country must reckon with racism in policing and take real action to prevent future Indigenous deaths in custody. As called for by the families of Aunty Tanya and Kumanjayi Walker, this starts with supporting community-led alternatives to policing and establishing effective and truly independent oversight of police.