Case Study

At a Lethal Intersection: the Killing of Ms Dhu (Australia)

Case study

Ms Dhu was a 22 year-old woman of the Yamatji-Nanda Nation and the Banjima People. Ms Dhu was taken into custody at the South Hedland police lock-up under a warrant of commitment for unpaid fines. She died within 44 hours of entering into the custody of Western Australian police.

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Aboriginal and Torres Strait Islander viewers are respectfully advised that this case study may contain images of and references to deceased persons.

All viewers are respectfully advised that this study contains images of and references to the deaths in custody of Indigenous peoples, Black people and refugees that may cause distress.

At the same time, each screen of these case studies testifies to target communities' strength and courage, as they respond to repeated deaths in custody through myriad creative forms, through lines of solidarity and through an unwavering call for justice.

‘My granddaughter has been dead for two years and I’ve still got no answers. I should be waking up every morning and kissing her cheeks – not ironing a t-shirt with her photo on it because she is dead.’

Aunty Carol Roe (Ms Dhu’s Nana), 2016

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Aunty Carol Roe and Yolanda hold ‘Forever Young’ banner for Ms Dhu at ‘National Day of Emergency: 25 Years Since the RCIADIC’ protest, Whadjuk Country (Perth), 2016. Photo: Charandev Singh.

A Young, Yamatji Woman

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Della Rae and Kobi Arthur Morrison perform ‘Forever Young’ outside Perth Magistrates Court on the 2nd anniversary of Ms Dhu’s death, Whadjuk Country, 2016. Video: Michelle Bui. 

Ms Dhu was of the Yamatji Nanda Nation family group on her mother’s side, and the Banjima family group on her father’s side. She was born in Port Hedland though she spent much of her childhood in Geraldton with her Nana Carol Roe. Her family describe her as ‘happy-go-lucky’ and ‘always with a smile on her face’. They remember her as caring, full of love and cheer, with a fierce sense of loyalty to friends and family.

Ms Dhu was only 22 years old when she was taken into police custody. When police responded to a report that Ms Dhu was being abused by her partner, they unearthed a number of her outstanding fines. This twist in events, casting her as an offender against the law, rather than a young woman in need of protection from family violence, led to her own arrest and shocking death less than two days later.

Ms Dhu’s status as a young Aboriginal woman meant that she was at the centre of a lethal intersection of gender, racial and economic violence: her experiences of interpersonal masculinist violence at the hands of an abusive partner,  her inability to pay minor fines that led to her incarceration and the racist violence she was subjected to by police and medical institutions both preceding and following her arrest–all contributed to her untimely death.

During her final 48 hours of life, Ms Dhu tried to convince police and medical officers that she was seriously ill but she was discredited, disbelieved and subjected to further physical injury. They repeatedly refused to provide her with due care, respect and the necessities for life.

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‘Justice for Ms Dhu’ Campaign image, 2014. Image: First Nations Deaths in Custody Watch Committee.

The Violent Occupation by the Colonial Prison Nation on Yamatji Country

Stretching fences across stone and sand

and far into sea? Their magnificent

jurisdiction of brutality. They are their

own totems. They worship their ‘order’.

‘In Marapikurrinya: for Ms Dhu’ poem by John Kinsella

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Crosses for Ms Dhu, placed by her family outside the South Hedland Police Station, 2015. Photo: Sebastian Neuweiller and Tyne Logan.

A Continuum of Violence Against Aboriginal Women

Of the 99 deaths that were investigated by the Royal Commission into Aboriginal Deaths in Custody (RCIADIC), eleven were of Aboriginal women, the majority of whom died in police custody. Three of the eleven women – Faith Barnes, Nita Blankett and Christine Lesley Ann Jones – died in Western Australia (WA).  Nita Blankett was at Bandyup Women’s prison when she suffered a serious asthma attack; like Ms Dhu she was disbelieved and denied life-saving care. Twenty years before Ms Dhu’s death, Janet Beetson died at Mulawa women’s prison. She was seriously ill but was dismissed as withdrawing from drugs.

Indigenous women now represent about 34% of the female prison population, despite making up only 2% of the total female population. In WA the ratio is closer to half. The deaths of Aboriginal and Torres Strait Islander women in custody have been afforded little visibility.

‘One of the points that hasn’t been really highlighted is that Aboriginal women have also died in custody, most of the publicity is centred around young Aboriginal men who have been in custody within a short few hours and have met their death. But there are Aboriginal women who have died in custody especially in Western Australia.’

Aunty Helen Ulli Corbett (Former Chairperson of the Committee to Defend Black Rights)

The official records rarely disaggregate data to consider Aboriginal and Torres Strait Islander women as a distinct, uniquely positioned group. Inquest reports, media articles and other sources must be cross-checked to determine the number of Aboriginal and Torres Strait Islander women who have died in prison or in police custody or police-related pursuits. Since 1990 we have counted 37 deaths of Aboriginal and Torres Strait Islander women in prison or police custody or police-related pursuits across Australia. More than half of these deaths have been in WA and NSW.

RELEVANT KEY TERMS: pervasive criminalisation

Pervasive Criminalisation

A woman pictured at a protest carrying a placard reading 'Unpaid fines should not be a death sentence' in one hand and an Aboriginal flag in another. She wears a shirt with Ms Dhu's photo on it and a plaited headband of red, yellow and black. Click here

National Day of Action, Whadjuk Country (Perth), 2014. Photo: Marziya Mohammedali. 

Ms Dhu was the subject of four Warrants of Commitment for fines and costs totalling $3622.34. These were accrued between 2009-2011 and started with a $200 fine. Based on the largest fine, which could be ‘cut out’ at $250 per day, Ms Dhu was to serve 4 days in custody. Like many other women who are incarcerated for the non-payment of fines, Ms Dhu had no other realistic means of paying these fines. Since 2010, one in every six Aboriginal people going to prison in WA has done so for fine default (not including people held in police custody, like Ms Dhu). In 2013, 1 in 3 women who entered the prison system did so to clear fines. Ms Dhu’s death has prompted policy reviews and renewed debate about ‘law and order politics’ and the incarceration of people for fine default. Despite recommendations, reports have continued to emerge from WA of other women being similarly targeted, including a mother of five whose outstanding fines were paid by a pensioner who felt compelled to intervene to prevent her from being imprisoned. One of Ms Dhu’s cousins was threatened with warrants of commitment for unpaid fines, while Keennan Dickie, an Aboriginal woman who sustained a broken rib after being robbed and assaulted, was taken into custody for unpaid fines following a check by police.

Following these events, the activist organization Sisters Inside initiated a crowdfunding campaign to raise funds to pay the court fines levied on Aboriginal women to stop them from being sent to jail for non-payment of fines in Western Australia.

‘Unpaid fines. To lose her life over that is a testament to how deeply ingrained the racism is in the system.’

Shaun Harris (Ms Dhu’s Uncle)


Police Discretionary Powers as Techniques of Racial Violence

High rates of incarceration for ‘good order offences’ reflect how the bodies of Aboriginal women and girls are violently regulated and policed in public space. The police treatment of Ms Dhu exemplifies the manner in which police discretionary powers can be mobilised as techniques of racial violence. They evidence the asymmetries of racialised power that inscribe police discretion – as to whether or not they will charge someone for ‘disorderly behavior’ (as is often the case with Aboriginal people) or whether they choose (as is invariably the case with white people) to let them off with a caution. Police discretionary powers, as techniques of racial violence, contribute to the over-representation of Indigenous people in Australia’s prisons as they criminalise Indigenous people in ways that often have cascading effects: for example, an Indigenous person who resists arrest may be charged, in turn, with offensive language and police assault – a combination known as the ‘trifecta.’

Ms Dhu’s fines for ‘disorderly behaviour’ included swearing at a police officer; however while in custody Ms Dhu herself was sworn at and degraded with no criminal or other consequences for the abuser. When former Sergeant Bond was asked whether he swore at Ms Dhu, he conceded he may have done so because ‘that’s the way we spoke to each other in the Pilbara’.

Aunty Carol raises her right fist in the air while holding a placard in the other hand outside the Coroner's Court in an act of resistance.

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Aunty Carol outside the court, Whadjuk Country (Perth), 2015. Photo: Charandev Singh.

‘The police could not see Ms Dhu as a victim who was deserving of protection and assistance – her Aboriginality denied her this status.’

Dr Hannah McGlade


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‘Hands Off Aboriginal Kids’ rally, Narrm (Melbourne), 2016. Photo: Charandev Singh.

Gendered Violence

Around 5pm on 2 August 2014, Ms Dhu was taken into custody under warrants of commitment for unpaid fines with her partner, Dion Ruffin, who was arrested for  breaches of a violent restraining order (VRO) against a former partner. Mr Ruffin was 17 years Ms Dhu’s senior. He was was known to police as a serial domestic violence perpetrator. Ms Dhu’s family had long held concerns about her safety and well-being with Ruffin, and made repeated attempts to get her away from him, including alerting police. Authorities entrusted with protecting Ms Dhu ignored evidence that she was a victim of severe domestic violence.

When they arrived at the lockup, Ms Dhu had some difficulty walking when she got out of the police vehicle. When questioned by First Class Constable Eastman, she indicated that she had a broken rib. At this point in time she was standing next to Mr Ruffin. The ultimately fatal sepsis that Ms Dhu suffered stemmed from injuries inflicted and re-inflicted by Mr Ruffin. No efforts were made to ensure that Ms Dhu was spoken to and assessed safely and in private. Ms Dhu was taken to Cell 3 and Mr Ruffin was placed in an adjacent cell.

‘She said that her man was flogging her and he done the broken ribs.’

The Late Mr Dhu (Ms Dhu’s Father)

Ms Dhu required safety, treatment, care and a timely, serious and effective investigation of the criminal family violence inflicted on her. Instead, the State criminalised her over unpaid fines and effectively legitimised and replicated the violent coercive control that she had been subjected to by her partner. The failure of police to respond to Ms Dhu’s disclosures and take seriously cases of family violence against Aboriginal and Torres Strait Islander women underscores that purveyors of state violence cannot be relied upon to prevent domestic violence. As anti-violence organisations like ‘INCITE!’ have advocated, alternative responses to gendered violence that do not promote the violence of the prison industrial complex are required.

The submissions of the First Nations Deaths in Custody Watch Committee to the State Coroner highlight the responsibilities of police to investigate domestic violence and the ways in which officers failed to fulfill their obligations to Ms Dhu.

RELEVANT KEY TERMS: pervasive criminalisation

Refusal to Protect

In 2002, the Gordon Inquiry into the response by government agencies to complaints of family violence and child abuse in Aboriginal communities made a series of recommendations that are largely yet to be implemented. In 2015 a report entitled ‘A measure of trust’ considered how WA Police evaluate the effectiveness of its responses to family and domestic violence. Issues raised by victims / survivors included a fear of being disbelieved, blamed or judged, a lack of confidence in the justice system, fear of retaliation and mistrust of the police. Many support services indicated that WA Police consistently fail to take breaches of Violent Restraining Orders (VROs) seriously. This was borne out in the case of Andrea Pickett, a Noongar woman from Perth, who had taken out multiple VROs against her estranged husband.

The 4 Corners episode, ‘A Matter of Life and Death‘ documents how the failure of authorities to respond effectively to the domestic violence experienced by Andrea Pickett and by the Japanese-Australian woman, Saori Jones, contributed to and enabled their murders. It also documents the relentless struggle of Andrea’s family to achieve justice and change from her murder.

A person holds a newspaper clipping of an article with the headline 'Agencies failed murdered mum'. Click here

Newspaper Article, 2012. Photo: Charandev Singh. An important research study conducted by Lilly Brown (University of Melbourne) considered the framing of Victorian-based print coverage of Aboriginal Family Violence. The preliminary findings were that there was an absence of media coverage relating to Aboriginal women as victims of violence, there was a tendency to generalise Aboriginal family violence and that the level of complexity used to frame Aboriginal family violence was often dependent on whether a community representative was the primary source of information or not. These issues can be considered when examining the reportage of Andrea Pickett and Lynette Daley’s murders in print media in Western Australian and New South Wales.

The Case of Andrea Pickett

Andrea was murdered by Kenneth Pickett on 12 January 2009 while hiding at her cousin’s house. At the time he was on parole in respect of a charge that on 14 February 2008 he had made a threat to kill her. Prior to her murder she suffered several violent attacks and multiple breaches of the VRO. She had sought the support of Crisis Care in the hope of finding a safe place for herself and her children, but was told that they were unable to accommodate her. She relayed her concerns to police, but they were largely sceptical and dismissive. No steps were taken to ensure her safety. For further details of Andrea Pickett’s story see our case study, Indigenous Femicide and the Killing State.

‘We walked out of there and she was like, nah, he’s going to kill me. They (the police) are not going to help me.’

Dianne (Andrea Pickett’s cousin)

Resisting Accountability: The case of Lynette Daley

Lynette Daley (also known as ‘Norma’) was a 33 year old mother of seven. She was described by her family as beautiful, loving and kind-hearted. She had survived previous relationships where men had inflicted multiple forms of violence and control against her.

On Invasion Day in 2011 she was subject to a prolonged and violent sexual assault at a time where she was highly intoxicated and could not have provided consent. She died the following morning and was found naked and bloodied on the Ten Mile beach near Iluka in NSW. A Report by 4 Corners entitled ‘Callous Disregard’, detailed the harrowing circumstances surrounding her death.

When questioned by police, Adrian Attwater, one of the men charged for her death stated, ‘These things just happen, man, as I said. Girls can be girls. Boys will be boys.’ The NSW Director of Public Prosecutions declined to prosecute in 2012 and declined to revive charges in 2014 following the Coronial Inquest. Community outrage led to an independent review of the case in 2016.  A two week trial was held in August 2017 following which the judge delivered a ‘guilty’ verdict. On 8 December 2017, Adrian Attwater was sentenced to 19 years with a non-parole period of 14 years and 3 months, while Paul Maris was sentenced to 9 years with a non-parole period of 6 years and 9 months.

For further details of Lynette Daley’s story see our case study, Indigenous Femicide and the Killing State.

A man stands to the left of the frame and a woman stands to the right of their frame. Both have their backs toward the camera and are looking to the sky at a flying eagle. Click here

Adrian Davies and Thelma Davis watch an Eagle fly past a memorial for Lynette, Ten Mile Beach, 2016. Photo: Rob Griffith. 

‘She was just a statistic with the DPP and with them. You know, it was just another Indigenous girl, we’ll sweep it under the carpet…I was wondering if it would’ve been two Aboriginal boys had done that to a white girl, I reckon they’d be still in jail.’

Gordon Davis (Lynette Daley’s Stepfather)

‘We know where they are now, we know they won’t do it to anyone else.’

Gordon Davis (Lynette Daley’s Stepfather), December 2017


 Dr Hannah McGlade, a Noongar human rights lawyer and Senior Indigenous Research Fellow at Curtin University, has long been writing on  the violence experienced by Aboriginal women and children and the pervasive culture of silence, inaction and marginalisation of victims / survivors. She has been involved in advocating around Ms Dhu’s case. In 2016, she addressed the UN at a panel discussion on the rights of Indigenous Peoples at the 33rd Regular Session Human Rights Council (from 42:30). In this address, she referred to the violent deaths of three young Aboriginal women: Ms Dhu, Andrea Pickett and Lynette (Norma) Daley.

‘Aboriginal women were absolutely suffering extreme violence and having no one to go to – the state is part of this problem…still now, you can see many very serious offences against a woman with no accountability in the justice system…’

Dr Hannah McGlade


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22 flowers were made for Ms Dhu by her Mother, Della Roe, and laid by the steps of the Perth Coroner’s Court by family members and supporters, Whadjuk Country (Perth), 2016. Photos: Charandev Singh.

A Non-Diagnosis

On the day that Ms Dhu was taken into custody she described her rib pain level as being ten out of ten. While she waited to be taken to the Hedland Health Campus (HHC) she could be heard constantly moaning and crying. Upon arrival, Nurse Lindsay recorded her pain score as three out of ten and allocated a triage score of 4 (low acuity).

‘Can you help me?…It’s hurting like hell.’

Ms Dhu, 2 August 2014

When Ms Dhu was examined, she was groaning in pain and recoiled when Nurse Dunn touched her. The Nurse responded with words to the effect of ‘I didn’t touch you’ or ‘I hardly touched you’, and allegedly rolled her eyes. Ms Dhu was immediately treated with suspicion and had her credibility questioned. During the Inquest, both Nurse Lindsay and Dr Lang suggested that an escorting police officer had told them that Ms Dhu only appeared to be in distress or pain after she was informed that she would have to spend time in the lockup overnight. Dr Lang said that she thought that Ms Dhu’s limp was ‘a little bit artificial’ like she was ‘playing up her symptoms’. She recorded an impression of ‘behavioural gain’ and a discharge diagnosis of ‘behaviour issues’.

‘The persistent assumption was that Ms Dhu was ‘faking’ her symptoms and was malingering, addicted, manipulative and hysterical. These entrenched racist stereotypes underpin and licence the physical ill treatment of Ms Dhu; indeed, it is only this framework of racist preconceptions that makes intelligible the inability of medical and custodial staff to recognize that she was seriously ill and to treat her with due care and respect.’

Suvendrini Perera (Statements for Ms Dhu)

Despite this non-diagnosis, Ms Dhu was given Endone, a strong analgesic, and Diazepam, a sedative agent and deemed ‘fit to return to police custody’. Much of Dr Lang’s evidence, including her description of Ms Dhu as ‘disruptive’, was unsubstantiated. The issue of Dr Lang’s reliability and credibility was given little attention.

‘When she cries out we want to come to her

or for others to do the same if we can’t be there’

‘Julieka’, poem by Tracy Ryan   Click here


Care Denied

On the afternoon of 3 August 2014, Ms Dhu again asked for help. First Class Constable George heard moaning from Ms Dhu’s cell. She told him she was finding it difficult to breathe and that she had asthma. Ms Dhu was taken from her cell, handcuffed and brought to the HHC for the second time.

Ms Dhu was seen by Nurse Hetherington who allocated her a triage score of 4. Her temperature was not taken and no pain score was recorded. A high temperature reading would have led to further tests and potentially allowed medical staff to detect and treat Ms Dhu’s illness. She was reviewed by Dr Naderi who noted a discharge diagnosis of ‘? withdrawal from drugs’ and ‘behavioural issues’. The Coroner did not question the plausibility of claims that he did not observe Ms Dhu moaning and that she showed no signs of respiratory difficulty.

Again, Ms Dhu was declared fit to be held in custody. Upon return from the HHC, First Class Constable George mocked the dying young woman,  ‘Paracetamol, paracetamol? After all that…hah!’

A man, raises a large square placard at a protest. His face and body are painted and an Aboriginal flag is draped around his neck. The placard reads, 'Black Deaths in Custody Ms Dhu. 22 yrs of age. South Hedland Police Station 4-8-2014. Inhumane treatment police officers, medical staff, country health service. Shame Western Australia.' Click here

Standing in Solidarity with Kalgoorlie protest, Whadjuk Country (Perth), 2017. Photo: Marziya Mohammedali.

‘They said she was faking it – how can you fake dying?…She wasn’t exaggerating the poor girl was dying.’

Della Roe (Ms Dhu’s Mother)

Killing Ms Dhu: ‘legal murder’

On the morning of 4 August 2014, Ms Dhu pushed the cell call button for the last time. First Class Constable Matier said something about ‘hospital’ to former Sergeant Bond who responded, ‘That would be the third time she’s been to hospital. She is fit to be held’. He told Ms Dhu ‘this is the last fucking time you’re going to hospital’. On that point he was right.

‘Help me. I can’t feel my legs.’

Ms Dhu, 12:06pm, 4 August 2014

At approximately 12:11pm on 4 August 2014, Senior Constable Burgess yanked on Ms Dhu’s right hand, pulled her up and lost grip. Ms Dhu fell backwards and struck her head on the concrete floor. Senior Constable Burgess checked the concrete floor for blood, but failed to check the state of Ms Dhu’s head. The Coroner’s inquiry focused on whether Constable Burgess manifested ‘contrition’ for the fall by saying sorry.

The law failed to name the fall as an entirely predictable outcome of Constable Burgess’s reckless and brutal handling of Ms Dhu.

Over the next hour, Ms Dhu complained that she could not feel her legs and that the rest of her body was going numb. At 12:30pm an entry was made in the custody system that read ‘Detainee appears to be suffering withdrawals from drug use and is not coping well with being in custody’.

‘I can’t move, I can’t move.’

Ms Dhu, 12:40pm, 4 August 2014

When the decision was made to take Ms Dhu to the hospital for the last time she was unable to get up and had limited use of her head and hands. In this state of near death, she continued to be criminalised. She was handcuffed while lying on her back on the mattress and then dragged across the floor, then carried by two police officers to the back of the police vehicle. When they arrived at the HHC, CCTV shows Ms Dhu appeared to be completely incapacitated. Yet no urgency was shown even at this critical last stage to get the her medical attention that might have saved her life.

Less than a year after Ms Dhu’s death, in the US Sarah Lee Circle Bear, a pregnant 24 year old Lakota woman and mother, was repeatedly told to ‘quit faking’ while in custody at Brown County Jail. Like Ms Dhu she was seriously unwell and died in her cell just two days after being arrested. The parallels between their final days are striking and demonstrate the disregard for Indigenous women North America and Australia alike.


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Carolyn Lewis speaking at ‘National Day of Emergency: 25 Years Since the RCIADIC’ protest, Whadjuk Country, (Perth), 2016. Photo: Charandev Singh.

Institutional Racism: South Hedland Police

Aunty Carol Roe and Ms Dhu's younger sister Yolanda are both bent over, standing in a garden outside the South Hedland Police Station. They are placing painted crosses in the ground beside a small tree they have planted in Ms Dhu's memory.

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Ms Dhu’s Nana, Carol Roe, and sister, Yolanda, plant a desert rose outside the South Hedland Police Station for Ms Dhu, 2015. Photo: Sebastian Neuweiller and Tyne Logan

The only member of the police force who showed any concern for Ms Dhu’s wellbeing was the most junior officer present, a fact that, as Michael Brull suggests, ‘tells us something important about the institutionalisation of racism among Australian police’.

The South Hedland Police have persistently denied they have a cultural problem; however, Ms Dhu’s death can be situated against a series of prior allegations of racism and misconduct.

  • February 2014: ‘Leon Elroy’ alleged that after being taken to the local police station, instead of being dropped home, the police ‘dumped’ him near the local rubbish tip.
  • April 2016: after a car chase involving a group of teenage boys, the ALS alleged that officers used excessive force when firearms were drawn and a gun was pointed at one of the teenage boys. A complaint was lodged on behalf of one of the boys who said he was assaulted and that he and another boy were strip searched at the South Hedland police station.
  • June 2016: two youths were allegedly picked up by police and taken to the town’s outskirts and dumped there.
  • July 2016: an off-duty police officer entered the Port Hedland station and was charged with possessing a firearm while intoxicated, unlawful damage and pointing a firearm at a person.

Institutional Racism: Hedland Health Campus

Institutional racism and racial profiling permeate the health care system which repeatedly sees Aboriginal women like Ms Dhu mistreated and denied medical care. Wiradjuri woman Naomi Williams, for example, was 26 weeks pregnant when she presented to an emergency department was told to take some paracetamol and go home. She was dead 24 hours later. Like Ms Dhu, she had septicaemia, but was stereotyped as a drug user and denied appropriate care.

Dr Sandra Thompson, expert witness from the WA Centre for Rural Health, suggested at the inquest that Ms Dhu might have been a victim of institutional racism because she was an Aboriginal woman in custody with a history of drug use. She proposed that these factors ‘coloured the way in which she was treated in the hospital environment’. Throughout the Inquest there was a refusal to acknowledge and interrogate the issue of systemic racism and how Ms Dhu’s Aboriginality informed the treatment that she received.

‘If that had been a white, middle-class person, there would have been a lot more effort made to come to the cause of the pain.’

Dr Sandra Thompson, expert witness

During the inquest, the failures of medical staff to properly diagnose and examine Ms Dhu were described as ‘deficient’ and rationalised as being a result of ‘premature diagnostic closure’. The role of racism in informing ‘premature diagnostic closure’ was refuted.

‘We do not have a culture of institutionalised racism toward Aboriginal patients at the hospital…I would completely reject that for our institution.’

Dr Ganesan Sakarapani, Senior Medical Officer at HHC


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Justice for Ms Dhu Protest outside Perth Coroner’s Court, Whadjuk Country (Perth), 2016. Photo: Alex Bainbridge.

Bodies Marked for Death

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Chant in solidarity with the family of Ms Dhu to mark the 2nd Anniversary of her death, Nauru camp, 2016.

Racialised bodies are marked for death in the colonial pursuit to deny Indigenous sovereignty and perform the sovereignty of the Australian nation state. This is demonstrated through the offshore killings on PNG and Nauru where the bodies of asylum seekers and refugees are weaponised to ‘deter’ prospective asylum seekers from challenging Australia’s ‘sovereign borders’. The interlinked nature of these deaths has been acknowledged in displays of solidarity between prisoners held on Nauru and anti-deaths in custody campaigns.

‘Ms Dhu’s pre-existing and extensive infection was not diagnosed at HHC. By this stage her osteomyelitus was well established. The manner of Ms Dhu’s death is by way of natural causes.’

State Coroner Rosalinda Fogliani

The narrative of Ms Dhu’s demise as an unavoidable one haunts the inquest and its findings. The Coroner framed Ms Dhu’s death as ‘tragic’, ‘unfortunate’, ‘regrettable’ and ‘sad’. The law was unable or unwilling to see the violence that Ms Dhu was subjected to by Dion Ruffin, by the police and by medical professionals,  all of whom were effectively exonerated. The denials, delays, verbal and physical abuse, misdiagnosis, non-diagnosis and active neglect by the state and it agents, were largely invisible to the law and to the formal record.

Sherene Razack writes of how the deaths of Indigenous people in custody are persistently ‘medicalized’. She argues that Indigenous bodies are regarded as bodies already marked for death. ‘The inquest stages Aboriginality as dysfunction, incurable illness, and threat to the healthy social body. Both an event and a place, the inquest transforms the colonial condition into a medical one, legitimizing the violence that is performed at the police station, on the streets and in the hospital, wherever settlers encounter Aboriginal people and demarcate between the human and less than human through acts of violence described as help.’ (Razack, Timely Deaths)


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‘We Stand in Solidarity with Aboriginal Australia’, Nauru, 2016. Photo: Supplied.

‘I am hurt, hurt so much, my heart is torn out…Sitting there questioning and asking all of that. What about our heart? We bleeding, we bleeding here. We just go all through this over and over again all the time; the worry if our kids are dead or alive.’

Aunty Carol Roe (Ms Dhu’s Nana), 2016

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Ms Dhu’s family outside Perth Coroner’s Court, Whadjuk Nyoongar Country (Perth), 2016. Photo: Charandev Singh.

The Inquest

The inquest into Ms Dhu’s death was initially intended to be held at the South Hedland Courthouse, but was later relocated to Perth. This move diminished the capacity of Ms Dhu’s immediate family and community to attend court and to bear witness to the coronial process. The inquest was scheduled to hear testimony from 38 witnesses within a 10 day period between 23 November – 4 December 2015. Following the conclusion of the medical witnesses the inquest was adjourned until March 2016. This put further strain on Ms Dhu’s family.

Throughout the inquest, Ms Dhu’s family and highly respected Nyoongar Elders were treated with disrespect. Day one of the inquest set the tone of the proceedings with an interrogation of the family. When police and medical witnesses were questioned they frequently responded with ‘I can’t recall’ which provoked frustration from the public gallery.

Some medical and police officers offered contrived apologies in court,   causing pain and offence. Objections and responses from the public gallery where the family sat were consistently met with a disciplinary approach. Elders were threatened and patronised.


Aunty Carol, Della Roe and Yolanda stand beside one another outside the Coroner's Court. Aunty Carol and Della both hold placards - one reads 'South Hedland 'Can't Recall' Police Station. Ms Dhu Death in Custody 4 August 2014'.
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Ms Dhu’s Nana Carol Roe, Mother Della Roe and sister Yolanda outside the Perth Magistrates Court, Whadjuk Country (Perth), 2015. Photo: Charandev Singh

Standard Operating Procedure

A placard carried at a Black Lives Matter protest and visible in the foreground reads 'A system cannot fail those it was never built to protect'. Another placard further back in the crowd reads, 'Who do we call when police murder?!' Click here

Black Lives Matter protest, Whadjuk Country (Perth), 2016. Photo: Marziya Mohammedali. 

Peter Quinlin (Counsel for Ms Dhu’s family): This was a typical night, wasn’t it? Or a typical shift? 
Constable Matier: Yes. It was. Yes. Being a Monday it’s—typically very busy with prisoners.

Quinlin: But also, it’s…there’s nothing really unusual about, can I suggest, the lack of attention given to Ms Dhu here. It’s pretty typical of the way in which the lookup operated? 
Matier: Yes, yes. I agree. Yes.

Ms Dhu’s time of death was recorded at 1:39pm, by which time officers from WAPOL internal affairs were already on a flight from Perth. At the end of their investigation, 3 managerial notices and 7 letters of correction were issued which indicated that officers had failed to comply with police regulations. During the inquest, it was clear that few officers had paid much, if any, attention to these letters. None of the officers involved were subject to any meaningful consequence.


No Accountability

On the morning of 16 December 2016, members of Ms Dhu’s family, community, campaign group and supporters alongside a swarm of lawyers, journalists and reporters anxiously waited outside Court 51 of the Perth Magistrates Court.

When the court was finally opened, the Coroner, at rapid pace, read through key summaries and recommendations and then handed down her inquest findings. White envelopes holding hard copies of the 165 page document, which included 11 recommendations, were handed to Aunty Carol Roe, Della Roe and Mr Dhu via G4S court security officers. No referrals to the Director of Public Prosecutions (DPP) or Worksafe WA were made.

Ms Dhu’s family considered that the Inquest failed to seek accountability and justice for Ms Dhu’s death.

According to Perera and Pugliese, the Coroner’s consistent deployment of terminologies such as ‘unprofessional’ and ‘inhumane’ instantiates a refusal by the state to recognise the violence of racism and consequent culpability for potentially criminal negligence that were evident throughout the case.

A group of people outside the Coroner's court hold A1 and A2 sized placards and a banner that reads 'Justice 4 Julieka'. Click here

Activists gathered outside court on the day of the Inquest Findings, Whadjuk Country (Perth), 2016. Photo: Charandev Singh. 

During the week before the 3rd Anniversary of Ms Dhu’s death, ABC 7:30 Report spoke to Ms Dhu’s family about their ongoing campaign for justice and struggle for accountability. They lodged a claim of misconduct leading to death with the Supreme Court of WA and a complaint of racial discrimination  to the Australian Human Rights Commission. The latter could progress to the Federal Court.


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Smoking Ceremony outside Perth Coroner’s Court, Whadjuk Country, 2016. Photo: Charandev Singh.

Male Violence Rendered Invisible

The Coroner characterised Ms Dhu’s relationship with Mr Ruffin as ‘dysfunctional’ and noted that despite her family’s desire for Ms Dhu to separate from him, she was ‘drawn back into the relationship, willingly‘ (emphasis added). The suggestion of free ‘will’ diminishes the reality that Ms Dhu was subjected to violent forms of control by her partner and shifts blame to Ms Dhu for not escaping this violence.  The Coroner also indicated that Ms Dhu did not previously report any incidents of domestic violence to the police but failed to interrogate the barriers, mistrust and fears that women, particularly Aboriginal women, might have in engaging with the police. This was particularly relevant in light of Ms Dhu’s prior experiences with the police which resulted in the fines that led to her incarceration.

‘Observing the Coroner’s court I saw little attention paid to Ms Dhu as an Aboriginal victim of domestic violence. There was no acknowledgement of Aboriginal partner violence, the interplay of race and gender and the inhumane treatment she received.’

Dr Hannah McGlade


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Flowers for Ms Dhu, Whadjuk Country (Perth), 2016. Photo: Charandev Singh.

The Visibility of State Violence

Two women carry a painted banner at a protest in the streets. It depicts an image of Dylan Voller strapped to a chair and hooded with an Australian flag. Blood drips down from the top of the banner. The word 'GENOCIDE' is printed at the bottom.

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Hands off Aboriginal Kids rally, Narrm (Melbourne), 2016. Photo: Charandev Singh. In July 2016, ABC 4 Corners broadcast ‘Australia’s Shame’ in which CCTV footage was shown from the Don Dale Youth Detention Centre. This included evidence of children being brutalised, tear gassed, held in isolation cells and tortured. The vision of teenager Dylan Voller hooded and strapped to a chair became an iconic symbol of state sanctioned violence within the juvenile justice system. As Amy McQuire writes, ‘Without video evidence, Australians find it hard to believe that Black Lives Matter’. 

Following the conclusion of the Inquest Ms Dhu’s family agreed that they would like the CCTV of her treatment in custody to be released. Despite this, the Coroner ruled against releasing the footage on the paternalistic grounds that it had the potential to ‘re-traumatise’ them and the broader Aboriginal community. FNDICWC made a submission supporting the family’s application to release the footage. Ms Dhu’s Uncle Shaun Harris led a tireless public campaign to release the CCTV footage that was eventually successful.

‘It’s traumatising yes, but it still needs to be put out there…They can’t hurt us anymore, but they can traumatise us more by still holding back the truth…There will never be any justice unless there is truth and accountability.’

Shaun Harris (Ms Dhu’s Uncle)

The CCTV Footage: What the Law Sees

134. Sergeant Bond, Senior Constable Burgess and Senior Aboriginal Police Liaison Officer Edwards then walked over to Cell 3. Mr Bond then walked away in order to obtain gloves. The other two officers entered the Cell 3. As depicted on the Cell 3’s CCTV (that had no audio), at 12.11 pm Senior Constable Burgess approached Ms Dhu who was still lying on her back and with her right hand grabbed Ms Dhu’s right hand to pull her up into a sitting position. She then lost her grip of Ms Dhu who fell backwards, striking her head on the concrete floor.

Inquest into the death of Julieka Ivanna Dhu, WA State Coroner,  11 December 2016

Suvendrini Perera and Joseph Pugliese write of the visual and documentary material, including CCTV footage, that provides evidence of the repertoires of violence enacted on Ms Dhu as a racialised body in custody:

‘What does the law see? On a silent monitor, the impact of flesh and bone on concrete; the reflexive movement of recoil of a young woman’s broken frame as it is “grabbed,” then falls backwards. Is there a small twitch in the arm that grabs, then “loses grip”? No moans, cries or curses to be heard, but a slight turn of heads to the reverberation of skull on floor, a reverberation that seems to run through a current on the screen to a shudder in our own bodies?’

‘A historical repertoire of gestural violence is reproduced and captured by surveillance cameras that police officers and camp guards know is recording their actions as a form of visual testimony that might yet be used as admissible evidence in either a court or coronial inquiry; yet their actions are shadowed by this knowledge to no visible effect. The evidentiary apparatuses of the state are rather transmuted into passive witnesses that become, both during and after the fact, instrumentalities that enable, if not provoke, the ongoing reproduction, with impunity, of a lethal institutional repertoire of gestural violence.’ (Perera and Pugliese, ‘What the Law Saw’)



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Projections onto the old East Perth police lock-up, Whadjuk Country (Perth), 2016. Photo: Charandev Singh.

Making Deaths in Custody Visible: Justice for Ms Dhu

Ms Dhu’s family continues to lead a tireless campaign for justice with the support of the First Nations Deaths in Custody Watch Committee. Shaun Harris (her uncle), Aunty Carol Roe (her nana) and Della Roe (her mother) have ensured that Ms Dhu will be remembered. Her death has been the most widely discussed and reported case of an Aboriginal woman in custody in Australia and this can be attributed largely to the work of her family and their supporters.

Just as Ms Dhu’s death can be situated within an extensive catalogue of deaths of Aboriginal and Torres Strait Islander women in police and prison custody, the activism surrounding her death can likewise be situated in a history of resistance that has frequently been led by Aboriginal women. As Carolyn Lewis, an auntie of Ms Dhu and co-chair of the First Nations Deaths in Custody Watch Committee, writes:  ‘women walking with Julieka have come together to fight for her, they’ve stood as one in solidarity and strength amongst each other, with care and love.’ The efforts of the community in response to Ms Dhu’s untimely death made visible the violence to which Aboriginal women continue to be subject in Australia’s custodial and medical institutions.


‘We want all parties to be held accountable, be it the partner who started all of this…and of course the police and health service…They are all accountable.’

Shaun Harris (Ms Dhu’s Uncle)

The struggle for justice continues.

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‘Justice’ flag at National Day of Action for Ms Dhu, Whadjuk Country (Perth), 2014. Photo: Marziya Mohammedali.

Ms Dhu

‘She wasn’t treated like a person. She wasn’t heard, she wasn’t seen, she was let down at every step of the way.’

Felix Riebl


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In response to Ms Dhu’s death in custody Felix Reibl wrote a song that was recorded with Marliya, an Indigenous girls choir as part of the Spinifex Gum project. A call-out for photos with the hashtag #iMissDhu was made to be incorporated into the video clip. This call-out was taken up by family members, activists and the broader community.

At a Lethal Intersection: the killing of Ms Dhu


This case study was collectively authored by the Australian hub of the Deathscapes project: Michelle Bui, Dean Chan, Suvendrini Perera, Joseph Pugliese, Ayman Qwaider, Charandev Singh.

To cite this research: Michelle Bui, Dean Chan, Suvendrini Perera, Joseph Pugliese, Ayman Qwaider and Charandev Singh. ‘At a Lethal Intersection: the killing of Ms Dhu’. Deathscapes: Mapping Race and Violence in Settler States, 2017,

Corresponding author:


Special Thanks: 

Aunty Carol Roe

Carolyn Lewis and the First Nations Deaths in Custody Watch Committee

Dr Hannah McGlade

The Late Marc Newhouse


Please Read

Aboriginal and Torres Strait Islander viewers are respectfully advised that this website contains images of and references to deceased persons.

All viewers are respectfully advised that the site contains images of and references to the deaths in custody of Indigenous peoples, Black people and refugees that may cause distress.