Coronial inquest hears: Dictor Dongrin’s death result of ‘serious deficiencies’

In 2022, two brothers were jailed after a family fight. Less than 48 hours, one of them died within the confines of Clarence Correctional Centre, with the circumstances now being probed in an inquest.

Aerial view of the Clarence Correctional Centre at Grafton. Photo supplied by Corrective Services, Serco.

A former South Sudanese refugee died within the confines of prison just 48 hours after being jailed, with a coronial inquest now hearing that “serious deficiencies” in care may have cost him his life.

A report by health experts was submitted to the coroner’s court suggesting that while CCTV showed no deterioration in Dictor Mayen Dongrin’s condition in custody, there was also no improvement – a “strong indicator that treatment was required.”

Mr Dongrin, 29, was taken into custody on June 11, 2022, alongside his brother Taban, following a family altercation that left their father injured.

Dictor Dongrin was found unresponsive in the Clarence Correctional Centre's Medical Holding room on July 13.

Less than 48 hours later, on June 13, 2022, he was dead at Clarence Correctional Centre - sparking a coronial inquest which commenced on Monday.

Crown Prosecutor assisting Anne Bonner told the Coroner’s Court in the upcoming days evidence will reveal an “accumulation of deficiencies” in both staff observations and adherence to Justice Health policies for alcohol and drug withdrawal prior to Mr Dongrin’s death.

The coroner’s court heard Dictor Dongrin was “a well behaved and humble boy” who completed his schooling in Coffs Harbour and worked at Costa with his father.

Ms Bonner said the inquest will hear evidence that prison policies were allegedly not complied with, with medical observations described as “seriously deficient.”

She told the court Mr Dongrin had struggled with alcohol abuse, and had been hospitalised four times after vomiting blood.

He also had a failing kidney but was not taking medication for it which Ms Bonner said he told police when he entered custody at Coffs Harbour.

Ms Bonner further described Mr Dongrin “shaky and unsteady on his feet” in CCTV footage from Clarence Correctional Centre, where he was transferred.

Dictor Dongrin was born in Kenya after his parents fled Sudan. Picture: Facebook

The first Crown witness called, nurse Laura Beverley, assessed Mr Dongrin on intake as being in “active withdrawal” from alcohol, noting he was “pale and withdrawn”.

The court heard she further recorded his existing condition of seizures, including one just two months prior, and his admission of drinking a cask of wine daily.

The court heard the cause of death was fatal cardiac dysrythmia with a contributing factor of chronic alcoholism.

Dictor Dongrin’s heartbroken parents, Moses and Rebecca Dongrin, sat in court during the Coffs Harbour proceedings.

The inquest is set to continue for five days in Coffs Harbour Coroner’s Court where Deputy State Coroner Rebecca Hosking will continue to review the circumstances leading up to Mr Dongrin’s death. .

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