An Indigenous man died slowly in his cell. A coroner says the prison could have prevented it

WARNING: Aboriginal and Torres Strait Islander readers are warned that the following story contains an image of a deceased person.

Aunty Donnis Kerr sobbed as she learnt her son didn’t have to die.

At the Coroners Court of Victoria on Monday, she heard coroner David Ryan reveal that the death of 32-year-old Indigenous man Joshua Kerr in custody, while on remand at the issue-plagued Port Phillip Prison, was entirely avoidable.

Aunty Donnis Kerr says her son was left to die alone in a jail cell while staff did nothing.Credit: Luis Enrique Ascui

Ryan also took aim at the prison guards and medical staff amid what he found were “ongoing issues” at the prison, in Truganina in Melbourne’s west, which is due to close next year.

Aunty Donnis said her son was left to die alone in a jail cell while prison and medical staff did nothing.

“How many times do we have to hear these words before we take Aboriginal deaths in custody seriously?” she said outside the court.

Aboriginal man Joshua Kerr died in custody in 2022.Credit: Supplies

“This is what is wrong with our system – the lack of care and compassion for human life, for Aboriginal lives.

“We are happy to hear that Port Phillip Prison is closing down. If they had closed down two years ago, maybe my son would be alive.”

The findings come a week after the Allan government announced the maximum security prison would close by the end of next year and inmates would be moved to other facilities.

The prison, which is operated by multinational security company G4S Custodial Services, is Victoria’s largest.

The facility has been in the spotlight over a number of recent incidents, including the suspension of eight prison officers this month while there was an investigation into an inmate’s injuries caused from slipping on his own waste.

Kerr was found dead in his cell on August 10, 2022, while being held on remand on allegations of carjacking in the state’s north.

In the hours before his death, Kerr lit a fire in his cell and was taken to St Vincent’s Hospital, where he was treated for burns on his hands and arms.

Despite his behaviour appearing erratic, the inquest into his death heard he was returned to the prison without a mental health assessment and found dead in his cell three hours later.

Joshua Kerr was a talented artist.

His mother said her son was born to Yorta Yorta and Gunnaikurnai parents and had followed in the footsteps of his late father, Steven Thorpe, in becoming an artist.

Aunty Donnis, who also goes by the names Donnas and Donna, was told her son’s body had been covered with bruises consistent with him being left to roll on the floor for hours before he died.

Robinson Gill principal lawyer Ali Besiroglu said his firm would take legal action against those involved in the death.

On Monday, the coroner found Kerr should never have been taken out of St Vincent’s Hospital and returned to prison without a proper discharge process.

The coroner was also critical of the prison’s policies, which meant a sign placed on the inmate’s door – that staff failed to properly communicate the meaning of – resulted in staff refusing to enter the unwell man’s cell.

Ryan said safety needs should not stand in the way of medical needs, and better clarity was needed between prison employees and medical staff.

“Josh’s passing was a preventable tragedy which has devastated his family and community,” Ryan said.

“All correctional and medical staff who came into contact with Josh on 10 August, 2022, were responsible for his safety. It is a collective responsibility and the circumstances of Josh’s passing clearly demonstrate that there needs to be more communication, co-operation and collaboration between correctional and medical staff, which recognises the shared responsibility to ensure the wellbeing of prisoners.

Joshua Kerr’s family finds comfort in his artwork.

“This has been an ongoing issue at Port Phillip Prison and was identified in the earlier inquest into the death of Billy Bazouni in 2022.”

The inquest into Kerr’s death comes a year after coroner Simon McGregor paved the way for significant changes to the way Indigenous people are treated by the state’s criminal justice system following the death in custody of Veronica Nelson.

McGregor, who was brought to tears during a four-hour reading of his findings last year, criticised a litany of systemic failures within the criminal justice, health and corrections systems that he said led to Nelson’s preventable death in inhumane and degrading circumstances.

He found that from the time of Nelson’s arrest on December 30, 2019, to her death four days later, she was culturally isolated and her human rights were repeatedly breached while she was on remand for alleged shoplifting.

McGregor also noted that a sign had been placed on Nelson’s cell door advising staff not to enter. That issue was highlighted by Ryan in his findings on Monday.

For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).

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