An Indigenous Victorian man who died in custody in 2022 was “visibly unresponsive” for 17 minutes before receiving medical treatment, after having earlier called out “I’m dying” with no action from prison staff, the state coroner’s court has heard.
Joshua Kerr, a Yorta Yorta and Gunnaikurnai man, died while on remand at Port Phillip prison on 10 August 2022. The Victorian coroner’s court on Monday began an inquest into the death of the 32-year-old.
In the hours before his death, Kerr lit a fire in his prison cell and was transferred to St Vincent’s hospital for treatment of burns on his hands and arms alongside tactical operations group (Tog).
The officers transported Kerr back to prison before he had been formally discharged and while he was awaiting the re-dressing of his wounds. When he returned, staff placed Kerr – who had previously disclosed he had ingested methamphetamine – in a cell within the on-site medical unit. The cell could be viewed via CCTV in real-time.
A directive was given by Tog officers that Kerr’s cell door was to remain closed unless their staff were present.
Over the next few hours, prison officials watched Kerr’s erratic behaviour via CCTV footage but no one intervened, the inquiry heard. Counsel assisting the coroner, Rachel Ellyard, said Kerr’s behaviour was “distressing and bizarre”, including flailing his limbs while on the floor and removing all his clothing.
At about 6.30pm Kerr called out “I’m dying” but there was no response from prison staff and it is unclear if the transmission over the intercom was heard, the court was told.
From 7.40pm Kerr began to deteriorate as his movements slowed, the court heard.
“It doesn’t appear that any action was taken by those who made those observations. Other than to document them,” Ellyard said.
The CCTV footage showed Kerr became “completely unresponsive” at 8.01pm before a code black – medical emergency – was called by staff. His cell was not entered until 8.18pm when Tog staff arrived and pulled Kerr out. Paramedics were called to the site and Kerr was pronounced dead just after 8.40pm.
“That’s a total of 17 minutes between Josh being visibly unresponsive and having his first access to medical treatment,” Ellyard said.
“He died in full view of custodial and health staff.”
Ellyard told the court that it was unclear why the directive to not open Kerr’s door had been given as CCTV and body-worn camera footage did not suggest he posed an active risk.
Karen Gibson, a supervisor at the prison, told the inquest that staff had the right to override the directive but acknowledged that in her experience employees followed the orders given to them.
Ellyard said the inquest would probe the cause of death as well as the medical treatment Kerr received at St Vincent’s and the medical monitoring at prison to help prevent similar deaths.
A postmortem sample found Kerr had 8.1 milligrams per litre of methamphetaminein his system which Ellyard said was “a very, very high level”.
The autopsy showed multiple bruises and abrasions to Kerr’s face, elbows, forearms and ankles, which the court heard was consistent with his movements in his cell. It found the cause of death was unascertained.
Kerr was in quarantine in his cell due to Covid risks after he had attended his uncle’s funeral in the days before his death. He had been awaiting trial for more than a year.
Ellyard said Kerr was a loving son, father, brother, partner and friend.
“Josh’s story is his own, but it is also a story which reflects the tragic reality for too many Aboriginal men. And it needs to be said that this was an Aboriginal death in custody,” Ellyard said.
An internal review conducted by the state’s Department of Justice and Community Safety found the response to the fire in Kerr’s cell was appropriate and efficient.
It concluded health assessments conducted on Kerr in the prison’s medical unit were inadequate and noted attempts to complete the assessments were hindered by the directive for his cell door to remain closed unless Tog staff were present.
The inquest before the coroner David Ryan continues.
