Coronial inquest: Joshua Kerr was another preventable Aboriginal death in custody

Jul 3, 2024

**Content warning: this piece contains the names of Aboriginal people who have returned to the Dreaming.

A Coronial inquest into the death of 32-year-old Yorta Yorta and Gunaikurnai man, Joshua Kerr, in Victoria’s Port Phillip Prison, has been deemed ‘a preventable tragedy’.

The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) pays tribute to Mr. Kerr’s Mother Aunty Donnis Kerr and her family for their strength, courage, and resilience throughout this extremely emotional and traumatic process.

This week, Coroner David Ryan presented his findings, identifying numerous failings in the lead up to Mr. Kerr’s death on 10 August 2022.

Coroner Ryan made seven recommendations which included training for corrections and medical staff to recognise and manage drug affected prisoners and the affect it has on their decision-making capacity.

Coroner Ryan also noted that in Mr Kerr’s case, there was a “disproportionate focus on security concerns”.

VACCHO is incensed by the ongoing systemic failings that continue to disproportionately impact Aboriginal and Torres Strait Islander people under State care.

The inquest heard that on the day of his death, prison staff did not enter Mr Kerr’s cell to check on him despite his cries that he was ‘dying’.

In the hours prior to his passing, Mr. Kerr had been taken to St. Vincent’s Hospital after sustaining significant burns to his hand and arms caused by a cell fire.

The inquest heard despite Mr. Kerr displaying erratic behaviour at St. Vincent’s hospital, the Tactical Operations Group officers made the decision to take him back to Port Phillip Prison without being discharged by medical staff.

Josh Kerr was found deceased in his cell three hours after his return to Port Phillip Prison.

In his findings, Coroner David Ryan noted there was a lack of continuity of care from St Vincents’ emergency department staff to correctional staff and found that if a proper discharge summary was provided then Mr. Kerr’s death could have been prevented.

VACCHO CEO, Dr. Jill Gallagher AO expressed her deep disappointment at the continued and ongoing failings of the corrections and healthcare systems.

“It is clear that the State is not equipped and does not have the expertise to take care of Aboriginal people”, Dr. Gallagher said.

“Yet again our families and our Communities have been severely impacted by a preventable tragedy. We need real care, real compassion, and real humanity within Victoria’s health and justice systems.”

“Enough is enough – we know what needs to change. Put Aboriginal health in Aboriginal hands or these preventable tragedies will keep happening.”

VACCHO would like to extend our deepest condolences to the families of Joshua Kerr as well as to all Aboriginal and Torres Strait Islander families that have ever been impacted as a result of systemic failures.

Download the Coroner’s Report into Josh Kerr’s death here

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VACCHO is the peak body for Aboriginal and Torres Strait Islander health and wellbeing in Victoria – the only one of its kind – with 33 Aboriginal Community Controlled Organisations as Members. VACCHO Members support over 65,000 Aboriginal and Torres Strait Islander people in Victoria, and combined are the largest employers of Aboriginal people in the state.