Aboriginal and Torres Strait Islander readers are advised that this article contains the image and name of a person who has died.
"Everyone comes up to me and says, 'your son was murdered'."
Leetona Dungay has had to relive the final moments of her son, David Dungay Jr, from the time of his death in 2015 to when she first walked inside the NSW Coroner's Court in Glebe three years later.
"The hardest thing about that was when I first went [in] and thinking what is this really gonna be all about?" she said.
Leetona's family would wait another year for the coroner to hand down their findings into David's death.
A NSW parliamentary inquiry last year found the coronial system was "experiencing very heavy workloads", is "overburdened" and "lacks sufficient resources to undertake its important work".
It made 35 recommendations, but more than half weren't supported by the government, including a key reform to require coroners to examine whether systemic issues played a role leading to any death.
The inquest found the 26-year-old died from cardiac arrhythmia while being restrained by corrective officers in a cell at Sydney's Long Bay Prison Hospital.
There were contributing factors, including his diabetes, antipsychotic medication, and extreme stress and agitation.
David refused to stop eating biscuits when guards rushed into the cell and restrained him. He was moved to another cell, held face down on the floor while being sedated, and died.
Body-worn camera footage captured some of David's last words. He yelled "I can't breathe" 12 times.
He was due to be released on parole in a matter of weeks after serving time for assault, aggravated attempted sexual assault and being party to a robbery.
"He was happy-go-lucky, he was outgoing and he was very supportive of the younger ones," Leetona remembers.
"We still miss him and wait for him to run home."
Leetona, a Dunghutti woman from Kempsey on the NSW Mid-North Coast, travelled the almost five-hour drive to Sydney throughout the inquest.
The hearings were split into three, taking place over several weeks between July 2018 and March 2019.
With her was David's nephew, Paul Silva, who said he was overwhelmed by a system he had never experienced.
"Those weeks were not only traumatic for myself but for my family simply because we didn't know what we were walking into, we hadn't experienced a death in custody within our family before," Mr Silva said.
The family were advised there would be things they "didn't want to see" or "didn't want to hear" but Mr Silva said the family "fronted up and took on the process".
Despite the Dungay family finally having their day in court, it's not what they expected.
Not only did the family travel hours to be in court, but they were also subjected to constant checks for contraband, were supported by unpaid community members, and had to raise funds for accommodation and parking.
"Many deaths in custody transpire outside of the Sydney region and the last thing the family want to do is go to an inquest and hear paragraphs about their deceased loved one and stress about finding a car park and miss out on crucial information from the hearing — it's simple little things like that that puts more anxiety on a family," Mr Silva said.
"[The whole thing] was mentally and physically draining."
Mr Silva said his family also went into the coronial process thinking there would be some accountability for his uncle's death.
"We know [now] the coronial process really only gives the cause of death and what's transpired, unfortunately, our family had to have that explained prior ... and that was really like a knife in the chest for us.
"But we still sit here seven years on determined to get that justice."
Sitting on the front porch of her Kempsey home, Leetona recounts memories of her youngest son.
"He used to go down to the shops here, kicking the footballs, kicking them that high it would bust every time... I had to buy a new football every pay day," she said.
Inside her lounge room, photos of a young David are displayed next to a large artwork of him, arms across his chest, with the words "Justice for David Jnr... Our Dunghutti Warrior".
No-one has ever been held responsible for his death.
The National Justice Project, a not-for-profit body, advocates for Indigenous families throughout the coronial process.
Its chief executive and principal solicitor, George Newhouse, said the failure of the government to support the inquiry's recommendation to examine systemic issues was "horrific".
"Until coroners start looking at systemic issues throughout healthcare, policing, prisons, youth detention and child safety ... you're going to see more Aboriginal and Torres Strait Islanders die in custody," he said.
"Thirty years ago, the royal commission identified that coroners had the ability to identify and expose systemic problems, and it was recommended then and yet today we are still seeing governments stonewalling the implementation."
Since the Royal Commission into Aboriginal Deaths in Custody handed down its final report in 1991, more than 500 First Nations people have died in custody nationwide.
Data from the Australian Institute of Criminology's National Deaths in Custody Program show there were 10 Indigenous deaths in custody in NSW between July 2021 and June 2022.
This is the largest number of deaths in the state since 1989-90.
The NSW/ACT Aboriginal Legal Service is currently supporting 30 families through the system.
At the moment, it's funded to have one Indigenous support worker and one advocate.
Acting head of the coronial unit, Steven Rees said adequate resourcing is desperately needed to make the process faster and easier for grieving families.
"When families are sitting in court and listening to information that long after the death it doesn't help them find answers that allow them to move forward it just re-traumatises them and those delays are not the fault of the coroner's court — those delays are the problem of the government," Mr Rees said.
An NSW government spokesperson said a task force had already been set up prior to the inquiry to reduce delays and improve families' experiences.
They said the government had committed $56 million for extra staff, including another full-time coroner and two Aboriginal Coronial Information and Support Officers.
The court also recently introduced a First Nations protocol to ensure investigations and inquests of Aboriginal people are "conducted in a culturally sensitive and appropriate manner."
Mr Silva said in the case of his uncle David, it was clear in the findings the cause of death was cardiac arrhythmia, or a heart attack.
"But use of force was contributing, you know if there wasn't six men on my uncle, he wouldn't have had a heart attack — he was a 26-year-old young, fit, healthy male," he said.
The Dungays are one of the families who have been through the coronial system, only to be left with more questions than answers.
Mr Silva said a new, independent, investigation could help.
"Many families have been asking for it for years," he said.
"The coronial process does not give that justice and that's the sad reality of it ... we want independent investigations to reassure the family members and community that it is being investigated appropriately and independently."
Legal advocates, like Mr Rees, said greater funding would lead to greater support and representation, and ultimately better engagement with the coronial process.
"I think that families would have a lot to gain, and they would feel like the process is something working for them," he said.
Meanwhile, Leetona refuses to give up on the people who have been traumatised by a struggling system.
She is pursuing a complaint through the United Nations about a violation of human rights over Indigenous deaths in custody.
Her June 2021 submission argues both the Commonwealth and NSW governments failed to protect her son's right to life and asks the UN to pressure authorities to "prosecute, try and punish" those responsible.
Leetona is also seeking justice for others, raising the issue of Aboriginal deaths in custody more broadly, to help other families like hers.
"When I'm finished with my son's case then I'll continue helping other people to get in the door just like I did over at the UN," she said.
After more than 18 months since filing her complaint, Leetona is still waiting for a response from governments — though this isn't slowing her down.
"We won't ever stop because within helping other people it [eases] my mind that I know I'm doing my son's work because he's not here to speak for himself and for other people around Australia," she said.
"We're gonna make sure this don't happen to any of our children again.
"I just hope our past and present victims come forward and enter the door for one big great big submission, and let's whack this system."
