Coroner's Act In the matter of Coroner's Findings and Recommendations into the death of Kunmanara Forbes pursuant to section 46B dated 2 December 2009
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information out of any of the staff there at that time. They were short staffed and I had to rely on another workers verbal assurance that she would follow through. I heard other evidence which suggested both directly and indirectly that there were problems with the efficient operation of the Mutitjulu Health Clinic at the relevant time. The notes made by Ms Sutterby were not able to be found by police. She gave evidence that she was discouraged by the clinic director from reporting her concerns about Kunmanara to FACS, unless the family agreed. Shortly after this, Ms Sutterbys employment was terminated much earlier than her contract had originally intended. There was very high staff turnover at the clinic in 2005 and 2006. I could not take this issue any further at this inquest because of the substantial delay in any of these matters of fact being investigated by police. For example, Ms Sutterbys notes, made in late 2005, were not searched for until October 2008. In those circumstances, I can draw no conclusions whatsoever from the fact that they could not be located. Witnesses were not asked to recall important conversations or events on this subject until Detective Butcher took over the investigation of this matter 18 months after the death. The question of why Ms Carlyle did not see the important medical notes in November 2005 is but one example of those events. The reason for the termination of Ms Sutterbys employment is another such example. In those circumstances, no reliable findings of fact about any role played by the Clinic or its staff in the relevant events can be made and I do not propose to attempt to do so. 23. 24. However, I think it can fairly be said that there were at least, governance issues plaguing the Mutitjulu community in 2005 and 2006. So much clearly emerged from evidence given (and my own observations) at my previous inquest into the deaths of two Mutitjulu men from petrol sniffing, held in 2005 which sat for one day at Mutitjulu itself. It is a matter of public record that the Australian government appointed an administrator to the 9
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