Coroner Voices Alarm Over Health Screening Delays After Indigenous Inmate's Death
A New South Wales coroner has issued a stark warning about potential risks associated with revised health screening policies for Indigenous inmates, following the tragic death of a member of the Stolen Generations in custody. The deputy state coroner, Harriet Grahame, stated she was "very troubled" by changes that could lead to critical health issues being overlooked among incarcerated Aboriginal individuals.
Fatal Incident at Silverwater Prison
Gregory Merriman, a 58-year-old Yuin man and direct descendant of the revered Yuin leader Umbarra, died at the Metropolitan Reception and Remand Centre in Silverwater, located in Sydney's western suburbs, in December 2022. The coroner's findings, released on Friday, revealed that Merriman was found unresponsive in his cell approximately 30 minutes after being exposed to CS spray, commonly known as tear gas.
Prison officers had deployed the spray to manage a fight in a common area of the facility. CCTV footage indicated that Merriman was not involved in the altercation and had made verbal attempts to calm others. A nurse conducting welfare checks on all prisoners affected by the CS spray discovered him lying unresponsive on the floor half an hour later.
Missed Opportunities in Healthcare
An autopsy determined that Merriman suffered an acute myocardial infarction due to ischaemic heart disease. In her comprehensive 60-page report, Grahame noted that his heart condition was asymptomatic but highlighted missed opportunities for improved care, such as initiating statin therapy to manage his slightly elevated cholesterol levels.
At the time of his death, policy mandated that all Aboriginal inmates aged 45 and over receive a chronic disease screening within 30 days of their initial reception screening assessment. Merriman had not undergone this screening, which Grahame described as inconsistent with existing protocols.
Policy Revisions and Concerns
Since the incident, the policy has been updated to require a chronic health assessment for all inmates with identified chronic conditions. For Aboriginal prisoners without such conditions, along with non-Aboriginal individuals over 55, a preventative health screening is now scheduled within 12 months of their initial assessment.
Grahame expressed significant apprehension about this extended timeframe. She emphasised that adequate health screening represents one of the few positive outcomes for those in incarceration. With many Aboriginal inmates serving short sentences, she warned that if screenings are delayed towards the end of the 12-month window, numerous individuals could be released before receiving necessary care.
"I am concerned the new policy constitutes a decrease in the level of service rather than a clear improvement," Grahame stated in her findings.
Systemic Issues and Recommendations
While Grahame did not make specific recommendations targeting Justice Health, she advised the commissioner of custodial services to update policies regarding the use of CS spray to enhance first aid responses for exposed prisoners. She also addressed Merriman's family, acknowledging that the over-incarceration of First Nations people remains a fundamental cause of persistently high deaths in custody.
"I accept that this issue is grounded in the ongoing effects of colonisation," Grahame remarked. "Until the broad causes of over-representation are properly addressed, the disproportionate number of First Nations deaths in custody will not reduce."
Grahame referenced an open letter from the state coroner in October, which highlighted that NSW recorded its highest-ever number of Indigenous deaths in custody, with 12 fatalities in 2025. This occurred during a five-year period where the Aboriginal prison population increased by 18.9%, while non-Aboriginal prisoner numbers decreased by 12.5%, and Aboriginal remand figures surged by 63%.
"These figures reflect – consistently with the sentiments expressed by Greg's family – that the entrenched over-representation of First Nations people in the criminal justice system is a systemic issue," Grahame concluded.
