As veteran nurse Lorraine Walcott sped 70 kilometres down a dark dirt road from one remote desert community to another on November 9, 2019, she had no idea the patient she was rushing to reach had already passed away.
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains an image of a person who has died, used with the permission of their family.
When she arrived in Yuendumu just after 9pm, she said the community was calm and all she could do was formally pronounce Kumanjayi Walker dead.
"He was in the first holding cell [of the police station] … and he was lifeless," Ms Walcott said.
Mr Walker had passed away less than an hour before she arrived.
The 19-year-old Warlpiri-Luritja man had been shot three times by visiting police officer Constable Zachary Rolfe, who then asked the nurse to check over his own wound.
Ms Walcott told the inquest Constable Rolfe's puncture on his left shoulder — where Mr Walker had stabbed him with a pair of scissors during an attempted arrest two hours earlier — didn't require stitches.
Constable Rolfe was later charged and acquitted of Mr Walker's murder.
The story of Mr Walker's death almost three years ago has long included vague chapters about the lack of medical attention in Yuendumu that night.
However, after a week of evidence from 10 NT Health staff, the coroner examining the police shooting has been able to piece together the reasons why health staff came to leave the community before he was fatally shot.
The break-ins
Early on the morning of November 9, 2019, nursing staff in Yuendumu were "huddled" together after being woken by attempted break-ins to several of their houses.
"The break-ins felt a bit more specific to health care staff," then 21-year-old graduate nurse Mathilda Starbuck said.
"That's a bit unnerving, that it felt more targeted towards us."
During cross-examination from the health department's lawyer, Tom Hutton, Central Australian Primary Health Care Manager Dr David Reeve told the court he was concerned about an "upward trajectory" in crime.
Mr Hutton: "On 6 November, the clinic manager's house was broken into. On 7 November, the clinic manager's car was broken into. On 8 November, there were attempted break-ins at the clinic manager's house, at nurse Vanessa Watts' house, at nurse John Alton's house and at graduate nurse, Lisa Meredith's house?"
Dr Reeve: "Yes."
Mr Hutton: "So, four separate staff houses in one evening, and [in] three of those houses, staff were present?"
Dr Reeve: "Yes."
Mr Hutton: "Tools, including a pick axe, had been found at Luana's [the clinic manager] house and, in addition to those incidents, two cars had been broken into that night, [midwife] Janine Rewaka's car had been broken into and the clinic car had been broken into. That's correct?"
Dr Reeve: "Yes."
Mr Hutton: "Those are very concerning circumstances for you as the general manager, I suspect?"
Dr Reeve: "Yes."
Dr Reeve said the only reason staff would be withdrawn from a community health clinic would be in the event of "extreme staff safety risks, or perceived risk".
The withdrawal
Within hours, the entire clinic was evacuated, and staff were sent to Alice Springs.
However, the coroner has heard "breakdowns" in communication between nursing staff in Yuendumu and management in Alice Springs meant the withdrawal did not follow the usual protocols and neither police nor Warlpiri Elders were properly consulted before the community was left with no local medical services.
The clinic's three Warlpiri staff members were also not included in meetings about the evacuation, which was an "oversight", according to clinical nurse manager – quality and safety, Helen Gill.
There was also confusion around whether staff were willing to stay in the community and who — either management or nurses — made the call to withdraw.
The decision to flee left the Yuendumu community, of around 800 people, with no local medical staff.
Nurse Cassandra Holland told the inquest she had offered to stay in Yuendumu and graduate nurse Mathilda Starbuck said, despite feeling unsafe, she did not necessarily request to leave.
Ms Gill told the coroner she was of the understanding that all staff had requested to withdraw from the community.
Suggestions for two Yuendumu-based staff to head to Yuelamu, a smaller community 70 kilometres away, were made.
Dr Reeve said he had "no idea" why that didn't happen.
He agreed that, if he knew in November 2019 that police had plans to increase their presence in the community, and that some of his staff wanted to stay in community, his support for the withdrawal of clinic staff could have been different.
The deceit
After Constable Zachary Rolfe fired three shots at Kumanjayi Walker inside house numbered 511, police were reminded there were no nurses at the health clinic where they planned to take the injured man to.
Instead, Mr Walker was transported to the Yuendumu police station, where desperate efforts to save his life continued in the cells, the cleanest part of the police station.
Meanwhile, 70km away, Yuelamu nurse Lorraine Walcott answered a call from Yuendumu police sergeant Julie Frost, requesting her immediate assistance.
However, at the same time, Ms Walcott and her only colleague, Heather Zanker, were responding to a call in their own community from the mother of a sick child.
"You never ignore a sick child," Ms Walcott told the coroner.
They quickly split up — Nurse Zanker to the Yuelamu child while Nurse Walcott prepared the ambulance for an emergency trip to Yuendumu.
"I thought it was a bit steep [to be asked to cover Yuendumu and Yuelamu] to tell the truth, given the difference in the size of the communities. We were a bit concerned about leaving Yuelumu unattended," Ms Walcott told the inquest.
By the time the Yuelamu nurses arrived in Yuendumu — around an hour and half after the first call — Kumanjayi Walker had passed away.
However, police asked them to stay in the community, using the ambulance as a "decoy" when officers later travelled to the Yuendumu airstrip to pick up additional police.
Ms Walcott said she didn't know why the ambulance was required but did as she was asked.
The coroner was told members of the Yuendumu community thought the ambulance heading to the airstrip meant Kumanjayi Walker was being airlifted to hospital — they didn't find out until the next morning that, not only had he passed away, but that his body remained in the police station.
Through his lawyers, Police Commissioner Jamie Chalker issued an apology to Ms Walcott for her involvement in the deception, which left her fearing for her life after rocks were pelted at her ambulance.
The nurse suffered a head injury and bruising when windows of the vehicle were smashed while she was driving back to the police station from the airstrip.
The clinic now
In the three years since Kumanjayi Walker's death, the coroner was told, a series of changes had been implemented across the NT Health Department to rectify the systemic communication issues that occurred on November 9, 2019.
However, "significant challenges" in recruiting and retaining remote health staff have continued to plague the department.
The current clinic manager, nurse Sally Halton, and general practitioner Amy Rosser said that, despite ongoing "riots and break-ins" in the community, they had never felt unsafe at work.
The coroner was told staff regularly treated injuries caused by "screwdrivers, tomahawks … and boomerangs".
"We had an incident recently where someone was leaving the clinic and had stolen scissors from the clinic," Dr Rosser said.
Since December 2020, 24-hour security guards have been employed to patrol health clinic premises.
When the inquest resumes next week, Constable Rolfe's colleagues — who deployed with him to Yuendumu on the day Kumanjayi Walker died — are expected to give evidence to the coroner.
