The most telling comments from the Inquest into the death of Miss Dhu by Coroner Ros Fogliani come at the very end of the Inquest findings on pages 160 and 161 in para 856,857,858, 859 and 860. She is explaining the reasons why Professor Thompson identifies Miss Dhu’s risk factors as follows:-
 

“In summary and with the benefit of hindsight, it is clear that there are many ways in which Miss Dhu was at risk; her Aboriginality and lack of resources, her age and inexperience at negotiating for help, her injecting drug use that is a risk factor for septicaemia, her living conditions, which increase her risk for staph infections, her Aboriginality and injecting drug use that mean she may be treated less well within mainstream institutional settings”.

 
Professor Thompson goes on in para 857 to describe this as “institutionalised racism” (p160 and 161)
 

“Institutionalised racism refers to societal patterns that have the net effect of imposing oppressive or otherwise negative conditions against identifiable groups on the basis of race or ethnicity. Institutionalised racism is manifested in our political and social institutions, and can result in the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin”.

 
Professor Thompson rightly identifies the culprit as the institutionalised racism of the Police and Medical staff as the greatest of Miss Dhu’s barriers to climb.
 
The Coroner goes on to point out in para 858 the Miss Dhu’s family submit that this is what happened when miss Dhu presented to the medical staff for treatment on the first instance at 8pm on the 2.8.14
 
She then recites in the very next paragraph (859) that:-
 

“I did not find that any of the HHC staff or police were motivated by conscious deliberations of racism in connection with their treatment of Miss Dhu, nor does Miss Dhu’s family make that submission. It is important to be clear on this point”

 
My question to both (so-called experts) Why is it raised if it is a non-issue? Why then define and dismiss it, when the dismissal fits almost word for word with the description of the institutionalised racism, everybody is at great pains to ignore. On every occasion Miss Dhu presented to the Medical Centre for treatment, Police all considered her to be “faking it”. As her Grandmother asked:-“What, faking her own death”. Medical staff consistently called it:-“ Behavioural issues and drug withdrawal”. Septicaemia develops slowly, in Miss Dhu’s case it took three days to take hold and kill her, sadly no one in charge of her care, cared enough to save her.
 
I believe it is raised because at the very first opportunity Miss Dhu was subjected to this institutionalised racism that eventually overwhelmed and then killed her. The sub-conscious intuitively racist decision making of all charged with ensuring her safety, failed miserably.
 
Who raised it first, why. If it was as notes to Miss Dhu’s incarceration, where was the confidentiality in the Police station, where innuendo very quickly became uncontested fact. Burgess, Bond, Matier all Police generally disregarded Miss Dhu’s right to adequate care and confidentiality while in their custody. The only time patient confidentiality became an issue for the Police was very close to her death. The Medical staff, Hetherington (did not take temperature or Xray),  Lang (did not believe Miss Dhu about the broken ribs), and others,  pft wouldn’t let em treat my dog let alone another human being. With the exception of Nurse Jones, none showed themselves in a good light and all succumbed to the institutionalised racism to the point where standard health checks like temperature and X rays were not done for Miss Dhu. Another case of murder by institutionalised racism is buried with Miss Dhu’s remains.
 
It is important to note on p48 the description of Premature Diagnostic Closure in considering whether Miss Dhu’s death was preventable, where Dr. Dunjey elaborated on the premature and deadly diagnosis of Miss Dhu.                                     
                                                                                                                                                                              
It is also important to note that the Coroner was not instructed to look for instances of neglect or findings of criminality against anyone. She leaves that for the racist state of Western Australia.
 
It is also important to note that before Miss Dhu was declared dead at 1:39 on the 4.8.14, internal affairs police were already on a plane to Port Hedland.
 
It is also important to note that Miss Dhu’’s death was preventable and she could have been saved if she had been properly diagnosed and treated on the first or second occasion presenting at the Medical centre. She was never formally diagnosed with anything until her Inquest when the Autopsy results were given.  Antibiotics could have saved her on either of these visits. It was simply too little too late on the occasion of her third and final fatal visit to the Hospital.
 
It is important to note that the WA Police made changes to its Lock Up Procedures Manual 18 days after the death of Miss Dhu, but made no admission of culpability to the Coroner. I think the Lock up update is their admission of guilt, conveniently covered up by the Coroner.
All are culpable, but will any be charged. I think not, and that is the GREAT crime in this beautiful land and it is still called Institutionalised racism.
 

Jenny Munro is a Kalare Wiradjuri Elder, community organiser and activist. She co-founded the Redfern Aboriginal Tent Embassy and has been a long term Aboriginal Housing rights campaigner. In 2015 she was awarded the Eddie Mabo Award for Social Justice. She is currently the CEO of Mudgin-Gal, a unique service run by Aboriginal women, for Aboriginal women. Mudgin-Gal means ‘women’s place’.