The New South Wales Deputy Coroner has highlighted complex failures in the way New South Wales Corrections and the state's prison health system supported an Aboriginal inmate who spent most of his life behind bars and died in custody.
57-year-old Kevin Bugmy died of a heart attack at Cessnock Correctional Centre in April 2019.
At 20 years old, Bugmy was jailed for life for murder, spent 36 years incarcerated and was "continually denied release without being offered culturally appropriate case management" once he was eligible for parole in 2000, the findings said.
Mr Bugmy's family are members of the Stolen Generations, he was taken from his family and country at a young age and spent his childhood in foster care and institutions.
He suffered from long-term substance abuse.
The Bugmy family’s supporters spoke outside the Sydney court where the findings were delivered. Source: NITV
'The parole system failed Kevin'
The deputy state coroner, Harriet Grahame said Mr Bugmy may have been institutionalised by the time he died, but also highlighted that he was never offered proper case management for issues that had "clearly been identified for decades".
The inquest found he was never offered a specific program to counter his chronic use of solvents, which were used while he was working in custody and likely caused his death.
It was also noted that Mr Bugmy was never offered drug and alcohol programs that had cultural safety in mind.
Magistrate Grahame agreed with Mr Bugmy's family's view that by the time he died, his 20-year struggle to get parole and substance abuse became intertwined.
"It is beyond the scope of this inquest to generalise, but I accept [the] claim that the parole system failed Kevin," Deputy Coroner Harriet Grahame said.
She recommended Corrective Services NSW implement a range of appropriate programs, including an Aboriginal-specific drug and alcohol program, and said she was "astounded" one did not already exist.
She also said Corrective Services should review its policies into prisoner transfers after Mr Bugmy was moved 50 times over 19 years, averaging about 3 times per year.
The coroner said "excessive interfacility transfers may be inhumane" and "may exacerbate social and family dislocation, health issues and cultural disconnection".
Lawyers representing Mr Bugmy's family welcomed the coroner's recognition of the inadequacies of his care in the prison system and welcomed the changes the inquest recommended, including a pilot allowing Aboriginal community controlled organisations to provide primary health care in New South Wales prisons.
But lawyer Jalal Razi from the Aboriginal Legal Service said during a press conference outside the coroner's court "We note these things are long overdue and should already exist".
Going further, both the Coronial findings, Mr Bugmy's lawyers and family talked about his poor treatment beyond the corrective and healthcare system while incarcerated.
Being taken away from his family by the state as a member of the Stolen Generations to his adulthood behind bars, compounded with the denial of his release, prevented him from living a meaningful life with his family, who he was disconnected from.
Aboriginal Legal Service Lawyer Jalal Razi said the service is waiting to see a coronial system with more teeth. Source: NITV
'Impossible for him to find stability'
Kevin's sister Aunty Doreen Webster spoke outside court and said that as members of the Stolen Generations, she and Mr Bugmy never knew each other as children but they tried to rebuild their family by contacting Kevin over the phone while he was in a Victorian prison and transferring him to New South Wales.
"Kevin should have had the chance to become an Elder to his family and community. But he never even had the chance to become a father," she said.
"Instead, he spent most of his life trapped in institutions that kept him from his family, community and culture. First as a ward of the state, and then as a prisoner".
"We tried to rebuild our family after the state tore it apart," she said.
"Once he got to New South Wales, Kevin was moved between jails 50 times over 19 years. We didn't have the means to go to him at every new prison".
"They were preventing us from having him in our lives. It was impossible for him to find stability," Ms Webster said.
Aboriginal Legal Service Lawyer Jalal Razi, who represented Mr Bugby's family said institutionalisation and the deficient health care system in New South Wales prisons are still putting other Aboriginal inmates at risk.
"This is the reality. For far too many Aboriginal people and their families (they) are left with that painful legacy for generations to come," Mr Razi said.
The inquest's recommendations included a more streamlined system that allows staff assessing prisoners for employment to clearly see whether there is a health or medical issue that might be an impediment to them working in a particular unit, such as Mr Bugmy's access to solvents while at work.
Also, Corrections review its policies around the movement of inmates between prisons, with a view of reducing them, avoiding excessive movement and paying particular attention to the rights of long-term prisoners such as Mr Bugmy.
It also recommended that New South Wales Corrections looks at increasing the cultural competency and safety of its workforce with ongoing training, supervision and leadership.
And the recommendation that Corrections and the Justice Health and Forensic Mental Health hold a high-level meeting to discuss how to better manage chronic inhalant use in custody, as a health issue.
Lawyer for the Bugmy family, Jalal Razi said outside court, that the Aboriginal Legal Service in New South Wales is waiting to see a coronial system "with more teeth, that can hold the powerful to account and can create real change".
"Too many recommendations from past coronial inquestS have been left on the shelf, written off too easily by powerful institutions and never put into action," he said.
"This must change".
"It's up to the New South Wales Government to ensure this court can play a role to prevent deaths in custody, not just investigate them after it's too late," Mr Razi said.
