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Updated: Jun 12, 2026

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum
Published on: August 5, 2020
Inquest into the death of Cameron Doomadgee
1High Security Inpatient Services, The Park - Centre for Mental Health, Sumner Park, Brisbane, Queensland. RussJ_Scott@health.qld.gov.au
Abstract:
Following the death in custody on Palm Island of an apparently healthy indigenous man, a coroner's inquest heard one witness testify that he saw the arresting police officer repeatedly punch the deceased who was on the floor of the watch-house. The deceased died from a ruptured liver and portal vein. The inquest also heard expert evidence including reports from two autopsies and the opinion of two pathologists and a surgeon. The coroner found that none of the medical evidence supported the finding that punches described by the witness were likely to have supplied the compressive force necessary to cause the deceased's catastrophic internal injuries. None of the parties during the inquest disputed the rejection by the expert forensic pathologist of the possibility that the punches described by the witness could have caused the fatal injuries. However, the coroner did not refer to the unequivocal expert evidence or to the circumstance that the expert opinion was undisputed. The coroner concluded that the police officer "lost his temper" and hit the deceased after falling to the floor, thereby "causing the fatal injuries". Section 50(5)(d) of the Coroners Act 2003 (Qld) provides for an appeal from a coroner's findings "that could not reasonably be supported on the evidence". The inquest and subsequent appeal decisions highlight the importance of evidence-based expert opinion, procedural fairness and the potential for outcomes from Coroners Courts to be consistent with the principles of therapeutic jurisprudence.
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