Kevin Bugmy, a member of the Stolen Generation, had given up all hope of being released from prison before he died as his substance abuse prevented him being paroled.
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"His story is one that brings great shame on white Australia," NSW coroner Harriet Grahame said on Wednesday.
Releasing her findings on the circumstances of the Cessnock prison inmate's death in April 2019, she said the care he received for chronic substance use over many years in jail was grossly inadequate.
The Barkindji man, who was 57 when he died, was separated from his family after his mother died when he was young.
He was made a ward of state and placed with various white foster carers, but spent most of his life in custody, starting with juvenile detention.
At the time of his death, he had been in prison for 36 years for a murder he committed when he was 20.
In that time he was never offered a specific program to counter his issues of chronic solvent use, nor offered drug and alcohol programs designed with cultural safety in mind, the coroner said.
The need to participate in such programs was recorded in most State Parole Authority decisions as a reason for his continued failure to be paroled.
"Accordingly, at an institutional level, Kevin's inhalant use was well known. However, it became clear that this knowledge was not properly passed on to relevant operational staff at Cessnock Correctional Centre," Ms Grahame said.
He was transferred there in January 2019, in his 50th prison transfer since 2000. The next month he started work in the prison's furniture business unit.
Corrective Services submitted that while some substances in the unit contained acetone, none contained all six combined solvents found in three plastic bags in Bugmy's cell.
But the coroner accepted that he obtained the solvents within the prison, such as from his workplace, from a prison officer or another inmate.
She also accepted the claim of his sister Doreen Webster that the parole system failed him, with his inability to get parole and substance use becoming intertwined.
"Kevin's case encourages the need for further investigation into the operation of the parole system and sentence length for Aboriginal people," Ms Grahame said.
"One cannot help but wonder how many long-term prisoners like Kevin are denied parole over decades, without ever having been provided adequate and culturally safe case management."
She found Bugmy died of severe coronary artery disease, likely caused by his use of inhalants in custody.
Among her recommendations, she said Corrective Services should introduce a system to assess any health or medical impediment for inmates to work in business units, review policies to reduce movements of inmates between prisons, and trial an Aboriginal-specific drug and alcohol program.
Australian Associated Press
