Ms Dhu inquest: Coroner criticises 'inhumane' WA police treatment before death in custody

The West Australian coroner has delivered a damning assessment of the treatment of an Aboriginal woman who died in custody, labelling police behaviour "inhumane" and saying her life could have been saved if doctors had properly diagnosed her.

Handing down her findings into the death of 22-year-old Ms Dhu, whose first name is not used for cultural reasons, Ros Fogliani also decided to release CCTV footage of the last hours of her life on August 4, 2014.

Ms Dhu had been detained at the South Hedland Police Station lock up for three days for unpaid fines totalling $3,622, but "suffered a catastrophic deterioration in her health" while in police custody, the coroner found.

Ms Fogliani has recommended the law be changed so people could no longer be imprisoned for the non-payment of fines.

But speaking outside the Perth Central Law Courts after the findings were delivered, Ms Dhu's mother Della Roe said she was not happy with the coroner's recommendations, because no-one had been held accountable for her daughter's death.

Ms Dhu had suffered two broken ribs after her partner threw her to the ground in April 2014, but one rib never healed properly and became infected.

The coroner found the infection entered her bloodstream more than once when she was injecting herself with amphetamines.

Ms Dhu was arrested on August 2 for the unpaid fines relating to a variety of offences, including the assault of an officer, before she complained of rib pain and was taken to the Hedland Health Campus.

But she displayed no signs of infection and was discharged back into police custody, with a doctor diagnosing her as having "behavioural issues".

Ms Fogliani said when Ms Dhu was taken to the hospital again the next day, her temperature was not taken, a chest X-ray was not performed and "errors were made and there was a missed opportunity to treat Ms Dhu for her infection".

"On this presentation, antibiotics would have been potentially life saving for Ms Dhu," Ms Fogliani said.

Ms Dhu suffered 'catastrophic decline'

On the morning of the August 4, Ms Dhu then suffered a "catastrophic decline" in her health, but the coroner found police officers thought she was faking her symptoms, including her collapse.

Footage which was played to the court at the start of the inquest shows Ms Dhu being dragged from her cell unconscious by police on the morning of her death and carried into the back of a police vehicle, as well as crying and telling police she was in pain.

She was taken for a third time to the Hedland Health Campus but died at 1:39pm.

"It is profoundly disturbing to witness the appalling treatment of this young woman at the lock-up on 4 August 2014."

Ms Fogliani said she was allowing the release of the CCTV tapes showing Ms Dhu at the police lock-up, but with footage of her arriving at the Hedland Health Campus redacted.

Scrap jail time for unpaid fines: coroner

The coroner made a series of recommendations, including that dedicated lock-up keepers be introduced at every WA police station where detainees were held, and mandatory training for those duties.

She also said there should be cultural competency training across the WA Police force to better understand the health concerns of Aboriginal people.

The training should involve Aboriginal people and be targeted to local community issues, Ms Fogliani said.

In a major recommendation, the coroner suggested the law be amended so a warrant authorising imprisonment was no longer an option in response to the non-payment of fines.

As an alternative, any imprisonment would be subject to a court hearing before a magistrate.

Ms Fogliani said alternatives to detention should be considered, such as increasing out-of-court options for low-level offenders and introducing community work orders.

The coroner also recommended a custody notification service be introduced in WA like those in Victoria and NSW, requiring a lawyer to be contacted when an Aboriginal person is detained.

Ms Fogliani expressed hope her recommendations would avoid another person dying in the way Ms Dhu did, where a number of police officers "disregarded her welfare and her right to humane and dignified treatment".

There were cries of "racism" and "shame on you" from the gallery in court after the coroner finished handing down her findings.

Speaking outside court, Ms Dhu's family said they were not satisfied with the coroner's findings.

"A human life and no-one got accounted for it, you know," Ms Roe said.

Police Commissioner Karl O'Callaghan said his officers failed in their basic obligations to Ms Dhu regarding her safety, welfare and dignity.

"I accept that we failed Ms Dhu in this regard. She was not treated with the right level of human compassion or dignity," he said.

He said four officers were sanctioned for their conduct at the time and no further action would be taken against them.