Coronial inquest into deaths of cultural leaders Big Brother and Little Brother recommends spit hood ban
The NT coroner has recommended the banning of spit hoods. (ABC News: Xavier Martin)
In short:
The coroner has made nine recommendations following an inquest into the deaths of two disabled Aboriginal brothers whose health deteriorated over a number of years spent homeless in Alice Springs.
One of the brothers was twice restrained with a spit hood while he lay dying in hospital.
What's next?
Although the coroner found the use of the spit hood did not contribute to the man's death, she recommended NT Corrections ban their use.
Big Brother and Little Brother were the sons of a stockman.
Born in the 1950s, two years apart, they were proud Arrernte and Alyawarr speakers known as hard workers and cultural role models to the younger members of their large extended family.
They died two months apart in 2023 and their names can no longer be used for cultural reasons — so they are now known as Big Brother and Little Brother.
In the lead-up to their deaths, the pair had spent many years homeless in Alice Springs as their health deteriorated.
That was despite both brothers being assessed for significant cognitive impairments and placed under the care of the Office of the Public Guardian (OPG).
And as Big Brother lay dying in hospital, he was twice restrained with a spit hood by Corrections officers supervising him.
Coroner Elisabeth Armitage investigated the events leading up to the deaths of Big Brother and Little Brother. (ABC News: Xavier Martin)
Northern Territory Coroner Elisabeth Armitage investigated the supports the men had received in their interactions with government agencies and the adequacy of their care at the Alice Springs Hospital.
In Big Brother's case, she also examined the appropriateness of the use of a spit hood, despite it not causing his death.
The joint findings and recommendations of her inquest, released yesterday, paint a picture of multiple missed opportunities to properly assess the brothers' needs.
Public Guardian, NDIS miss opportunities for support
By the late 2010s, the Public Guardian had been appointed to control both Big Brother and Little Brother's personal and financial decisions, due to their disabilities.
Both had NDIS packages and aged care assessments.
But despite this, both brothers were homeless, lifestyles that the coroner said were "known to contribute to poor health outcomes and increased mortality risks."
In particular, the coroner found "homelessness and related food insecurity likely contributed" to Big Brother being diagnosed with a brain injury known as Wernicke encephalopathy in 2021, also associated with high alcohol consumption.
The NT's homelessness figures are 12 times the national rate, with 87 per cent of those homeless in the territory being Indigenous. (ABC News: Xavier Martin)
Although the coroner heard evidence the two men turned down offers of accommodation, she was not satisfied they understood their options, given the agencies had "very limited capacity to communicate" with the brothers without the use of Arrernte and Alyawarr interpreters.
The coroner also found despite the NDIS and OPG both supporting Little Brother, "no-one was formally responsible" for helping him to continue taking medication.
She noted there was confusion between the OPG and NDIS about the role of each agency in managing his case and advocating for Little Brother's interests.
Since the men's deaths, the OPG implemented an alert system to flag those under their care who are homeless for more than three months.
While the two men reportedly turned down accommodation, the coroner says without interpreters they may not have understood their options. (ABC News: Steven Schubert)
Little Brother took 'own leave' from Alice Springs hospital
By the time Little Brother was admitted to hospital in July 2023, he was very sick, with the consultant doctor finding he was "at risk of passing away".
Despite this, Little Brother took his "own leave" from the hospital, exiting the building clothed in nothing but a hospital gown.
Soon after, he was taken to hospital, where he died from "multi-organ dysfunction" due to hypothermia, along with other contributing causes.
The coroner says Aboriginal Liaison Officers often help encourage patients to stay in hospital until their treatment is complete. (ABC Alice Springs: Xavier Martin)
NT Health conceded it should have actively considered assigning a staff member to supervise him.
The coroner said Aboriginal Liaison Officers can help reduce the likelihood of patients leaving the hospital before their treatment was finished, but had only been rostered during business hours, and were unavailable when both brothers were admitted.
But the coroner was satisfied NT Health provided appropriate care at the hospital and that it was working.
Big Brother was in 'vulnerable position' prior to his death
Big Brother was in and out of prison while he was homeless and was in Corrections's custody when he was taken to Alice Springs hospital in September 2023.
While in hospital, Big Brother spat on Corrections officers and was restrained with a spit hood twice, causing distress to him and his family.
The coroner said while a spit hood did not contribute to Big Brother's death, the evidence to justify its use was still "insufficient". (ABC News)
The coroner said he was a "very sick man in a particularly vulnerable position," and his "difficult behaviours were not intentional."
"They arose from his cognitive impairment and in response to the situation in which he found himself where he was unable to communicate his needs and no-one spoke his language."
However, the coroner said she did not blame the corrections officers involved for using the spit hood, finding them to be compassionate and understanding.
She also found that the spit hood did not lead to Big Brother's death, which was ultimately attributed to his pneumonia and heart disease, along with other contributing causes.
However, the coroner did note the medical evidence suggested Big Brother was in the spit hood for "dangerously too long".
She also found the evidence was "insufficient to justify the use of spit hoods in a hospital or any other setting".
Alcohol, cognitive impairment service gaps
The coroner found both brothers had abused alcohol over a long period of time, which was a "significant factor in their poor health."
She said they could have been linked in with treatments on occasions when they presented to hospital.
Although medical records indicated that they did receive "acute care," there were gaps in the availability of transitional treatment.
The coroner also found that Big Brother should not have been in prison, due to his cognitive impairments.
The coroner found that Big Brother should not have been incarcerated given his cognitive impairment. (ABC News: Hamish Harty)
However, she said there were no medium to long-term residential facilities for people with "higher level" cognitive impairment in Alice Springs, let alone services accessible to non-English speakers.
She said that posed a risk that more people like Big Brother would end up in prison and hospital "at great expense and harm to the broader community."
The coroner made nine recommendations, including banning the use of spit hoods, improving the OPG's systems to identify when people are homeless for extended periods of time while in their care, and developing a strategy to improve how they engage with Aboriginal and Torres Strait Islander people.
Noting the family believed police should have engaged an elder to formally identify Little Brother's body, she also recommended NT Police's Cultural Reform Command review its protocol for this procedure.