Today is the first day of the coronial inquest into the death of Josh Kerr. Josh’s family ask that you please show support and attend the coronial inquest. For those unable, you can join online, and we will be tweeting under #JusticeForJoshKerr 
Josh was a proud Yorta Yorta and Gunnai-Kurnai man. He was a talented artist, a loved father, brother, son and cousin to many.
This morning his family held a smoking ceremony in front of the Coroner's Court.
#JusticeForJoshKerr
This morning his family held a smoking ceremony in front of the Coroner's Court.
#JusticeForJoshKerr
On 10 August 2022, Josh died in custody while on remand awaiting trial. He was only 32 years old. In his last moments, he was locked in a medical unit cell at Port Phillip Prison, which was supposed to be monitored by prison guards and health staff. #JusticeforJoshKerr
Today we will be sharing some distressing content from the court proceedings about the circumstances of Josh's death in custody, and we urge everyone to take care while reading and sharing.
#JusticeForJoshKerr
#JusticeForJoshKerr
It took 18 minutes to get to Josh after his body became motionless. He could not be brought back to life. Earlier that day he had been removed from St Vincents hospital.
#JusticeForJoshKerr
#JusticeForJoshKerr
Coroner David Ryan acknowledges the presence of Josh’s Family and the distressing nature of both the “circumstances of his passing” and this process. #JusticeforJoshKerr
The Coroner apologises that the smoking ceremony organised by the court had to be rescheduled.
Instead, Josh's family and the Dhadjowa Foundation organised their own smoking ceremony outside court.
#JusticeforJoshKerr
Instead, Josh's family and the Dhadjowa Foundation organised their own smoking ceremony outside court.
#JusticeforJoshKerr
Counsel Assisting (CA) the Coroner, Rachel Ellyard, delivers her opening, describing the days before Josh’s passing. #JusticeforJoshKerr
Counsel Assisting describes an incident where a fire in Josh's cell left him with burns to his hand.
The prison’s psychiatric nurse upgraded Josh's psychiatric status after he said that he wished he had died in the fire.
#JusticeforJoshKerr
The prison’s psychiatric nurse upgraded Josh's psychiatric status after he said that he wished he had died in the fire.
#JusticeforJoshKerr
Following the fire in Josh’s cell a decision was made by clinicians that Josh required further medical assessment and treatment following the fire in his cell.
Josh was taken to St Vincent’s hospital.
#JusticeforJoshKerr
Josh was taken to St Vincent’s hospital.
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CA: Observations were made that Josh [at the hospital] was verbally aggressive to some nurses and he was agitated.
#JusticeforJoshKerr
#JusticeforJoshKerr
CA: Another question is the decision making of operations officers and supervisor who appear to have made an assessment that Josh had refused treatment [at St Vincent’s] and was behaving in such a way as to require medical escort be cancelled on safety grounds #JusticeforJoshKerr
CA described evidence that the decision to cancel medical escort was not in consultation with doctors.
CA: Josh was taken away from hospital meaning he was not formally discharged and trained clinicians were not aware that he was going until after he had at the time he left.
CA: Josh was taken away from hospital meaning he was not formally discharged and trained clinicians were not aware that he was going until after he had at the time he left.
[We note that some of the descriptions shared today of Josh may be upsetting, and contain language used by Corrections and other prison staff.]
#JusticeforJoshKerr
#JusticeforJoshKerr
CA: CCTV and body worn camera footage is available depicting Josh's return and placement in the Medical Unit at Port Phillip Prison.
His behaviour was described as “erratic and heavily under the influence”.
#JusticeforJoshKerr
His behaviour was described as “erratic and heavily under the influence”.
#JusticeforJoshKerr
CA described his escort to the cell, the removal of standard prison clothes, and the replacement of these with garments that would “prevent self-harm”.
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#JusticeforJoshKerr
Josh was then left in his cell.
CA: No one ever entered Josh’s cell until after he'd been identified as being unresponsive on the floor... in excess of 10 mins...
The reasons for Josh not being fully medically examined will be explored in this inquest.
#JusticeForJoshKerr
CA: No one ever entered Josh’s cell until after he'd been identified as being unresponsive on the floor... in excess of 10 mins...
The reasons for Josh not being fully medically examined will be explored in this inquest.
#JusticeForJoshKerr
CA: The directive [to keep the door to Josh’s cell shut] ... profoundly influenced the ways that Corrections and medical staff responded to Josh.
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#JusticeforJoshKerr
Once Josh was alone in his cell, he removed all his clothes.
CA: Josh’s behaviour was consistently & medically bizarre... there's the possibility that as time passed, some of it was a kind of a seizure. This will be explored during the medical evidence.
#JusticeforJoshKerr
CA: Josh’s behaviour was consistently & medically bizarre... there's the possibility that as time passed, some of it was a kind of a seizure. This will be explored during the medical evidence.
#JusticeforJoshKerr
CA: Josh used the intercom. He can clearly be heard saying “I’m dying”.
#JusticeForJoshKerr
#JusticeForJoshKerr
CA: The medical nurse attended Josh's cell to give him a sedating injection. For reasons that will be explored, the cell door was never opened and that injection was never given.
#JusticeForJoshKerr
#JusticeForJoshKerr
CA: From 7.40pm Josh began to deteriorate. He is recorded as screaming, yelling and behaving strangely.
It doesn’t appear that any action was taken, other than documenting [the behaviour], by those who had made those observations.
#JusticeForJoshKerr
It doesn’t appear that any action was taken, other than documenting [the behaviour], by those who had made those observations.
#JusticeForJoshKerr
CA: [Josh’s] body movements start to slow down... He was on his stomach next to the toilet seat w his left arm over the toilet seat around 7:55. Josh's movements became less pronounced... The last movement can be clearly seen on the CCTV footage in the 8:01pm. #JusticeForJoshKerr
CA: A Code Black was called about 10 minutes later, there was a further 11 minutes before operators opened the door to allow medical treatment.
CA: There were 17 minutes between Josh being visibly unresponsive and having his first access to medical treatment. #JusticeForJoshKerr
CA: There were 17 minutes between Josh being visibly unresponsive and having his first access to medical treatment. #JusticeForJoshKerr
CA: The unit that [Josh] was in at St Paul's Unit is one of the closest units from the front monitoring centre. It would ordinarily take people a few minutes to walk briskly from one point to the other. #JusticeForJoshKerr
Josh’s cause of death was listed as medically unascertained, but Counsel Assisting suggests that based on evidence that will be heard at the inquest, the Coroner may be able to make a finding on cause of death. #JusticeForJoshKerr
CA recounts some of Josh’s early life, including his mother’s removal from her family as part of the Stolen Generation.
“This Court is painfully aware of the over-representation of Aboriginal people in this court and in prisons"
#JusticeForJoshKerr
“This Court is painfully aware of the over-representation of Aboriginal people in this court and in prisons"
#JusticeForJoshKerr
The court hears that Josh’s artwork was absolutely breathtaking.
Some of Josh’s artwork is displayed outside the Coroner’s Court today. #JusticeForJoshKerr
Some of Josh’s artwork is displayed outside the Coroner’s Court today. #JusticeForJoshKerr
CA: An inquest cannot resolve all of the questions that a Family has about the passing of their loved one… it cannot do justice to the totality of someone’s life.
#JusticeforJoshKerr
#JusticeforJoshKerr
This inquest is focused on the medical causes of Josh’s death and the circumstances of his passing.
CA outlines several areas of interest to the Coroner in this inquest:
1. What were the causes of Josh's behaviour after the incident in his cell.
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CA outlines several areas of interest to the Coroner in this inquest:
1. What were the causes of Josh's behaviour after the incident in his cell.
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2. Thinking about Josh's treatment accident, what assessment and treatment did Josh require?
3. What assessment & treatment did Josh receive & who was responsible for decision making regarding this... incl his capacity to consent to or refuse treatment?
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3. What assessment & treatment did Josh receive & who was responsible for decision making regarding this... incl his capacity to consent to or refuse treatment?
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CA described the JARO [Justice Assurance and Review Office] review into Josh’s death, which found that the way in which Josh was transported to and from hospital “fell short of quality expectations, was poorly planned.”
#JusticeforJoshKerr
#JusticeforJoshKerr
CA: The JARO review found that the decision to cancel the [medical] escort was “made without appropriate consultation.”
The JARO report also found that the way Josh was strip searched on return to prison was contrary to policy.
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The JARO report also found that the way Josh was strip searched on return to prison was contrary to policy.
#JusticeForJoshKerr
CA: Attempts to have completed a health assessment were hampered by the TOG directive that Josh’s cell door had to remain closed.
No dynamic risk assessment was conducted even though there were threats to Josh’s health.
#JusticeforJoshKerr
No dynamic risk assessment was conducted even though there were threats to Josh’s health.
#JusticeforJoshKerr
CA: The [JARO] review concluded that… there were gaps in his mental health management... and a delay in opening the cell door, even after the Code Black, and a delay in calling an ambulance.
#JusticeForJoshKerr
#JusticeForJoshKerr
CA: Josh was alone. Many people were watching and he was all by himself.
He died in full view of custodial and health staff, having been removed from hospital earlier that day for reasons which remained a bit unclear.
#JusticeforJoshKerr
He died in full view of custodial and health staff, having been removed from hospital earlier that day for reasons which remained a bit unclear.
#JusticeforJoshKerr
The court adjourned for morning tea.
Court resumed and the first witness, Gordon Frost, a registered mental health nurse who worked at Port Phillip Prison. He was the “risk nurse” at the time of Josh’s death.
#JusticeforJoshKerr
Court resumed and the first witness, Gordon Frost, a registered mental health nurse who worked at Port Phillip Prison. He was the “risk nurse” at the time of Josh’s death.
#JusticeforJoshKerr
CA: [Y]ou refer to your role that day as being the risk nurse. What does that involve?
Mr Frost: We go out to the person who is at risk to determine his mental state and whether he is at risk or not.
He says the risk nurse also attends crisis calls.
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Mr Frost: We go out to the person who is at risk to determine his mental state and whether he is at risk or not.
He says the risk nurse also attends crisis calls.
#JusticeforJoshKerr
Mr Frost says that G4s will alert the risk nurse to any issues, and then it’s the job of the risk nurse to go out and determine if the person needs to be put on watch.
His evidence includes a risk referral he conducted, and the interim risk management plan.
#JusticeforJoshKerr
His evidence includes a risk referral he conducted, and the interim risk management plan.
#JusticeforJoshKerr
CA: 'S' rating relates to risk that prisoner may self harm, and 'P 'rating relates to mental health history. As the risk nurse you are primarily focused onpeople who at risk of self harm?
Mr Frost: Yes.
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Mr Frost: Yes.
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CA: You became aware of Josh about 9:45am following a Code Red.
Frost: ...I heard the code red, found out who it was, looked up his history and then I raised the at risk referral myself, just to facilitate things… Then went down and assessed [Josh].
#JusticeforJoshKerr
Frost: ...I heard the code red, found out who it was, looked up his history and then I raised the at risk referral myself, just to facilitate things… Then went down and assessed [Josh].
#JusticeforJoshKerr
CA: At the time you went down to meet Josh, what did you know about him and his background?
Frost: I was aware that he had attended a funeral the day before.
Frost explains he was concerned with this as it might relate to risk and possible suicide attempt.
#JusticeforJoshKerr
Frost: I was aware that he had attended a funeral the day before.
Frost explains he was concerned with this as it might relate to risk and possible suicide attempt.
#JusticeforJoshKerr
Content warning: the next posts refer to suicide and self-harm.
CA: What was your intention in going to meet with [Josh]?
Frost: My main intention was to determine if the fire he lit was an act of self harm and depression or some other reason… I needed to determine if [Josh] wanted to end his life.
#JusticeforJoshKerr
Frost: My main intention was to determine if the fire he lit was an act of self harm and depression or some other reason… I needed to determine if [Josh] wanted to end his life.
#JusticeforJoshKerr
Frost: At that time, the general nurses had taken him to a medical centre in between the two units…I said to him, “is this an attempt at self-harm?”. I had to ask a number of times.”
#JusticeforJoshKerr
#JusticeforJoshKerr
Asked about how Josh was presenting, Frost describes him as "restless", and “he was polite to me and answered my questions…”
“I did feel he was agitated & restless… he did get up at one stage to put his hands under the tap water.. He had some severe burns” #JusticeForJoshKerr
“I did feel he was agitated & restless… he did get up at one stage to put his hands under the tap water.. He had some severe burns” #JusticeForJoshKerr
CA: Did the burns appear to be troubling him?
Frost: It was a severe burn, like wow, he was peeling the skin off as he was talking to me…
#JusticeforJoshKerr
Frost: It was a severe burn, like wow, he was peeling the skin off as he was talking to me…
#JusticeforJoshKerr
CA: Did you question him about his motivations about starting the fire?
Frost said that Josh was paranoid and agitated from drug use.
Frost: He said, I don’t know why someone hasn’t come and visited. He said he lit the fire because he was paranoid.
#JusticeforJoshKerr
Frost said that Josh was paranoid and agitated from drug use.
Frost: He said, I don’t know why someone hasn’t come and visited. He said he lit the fire because he was paranoid.
#JusticeforJoshKerr
Frost described Josh's response to why he lit the fire.
Frost: He said it was a stupid thing to do, I’ve got 4 kids and a family. But at the end of that statement he said “I wished I had died.”
#JusticeforJoshKerr
Frost: He said it was a stupid thing to do, I’ve got 4 kids and a family. But at the end of that statement he said “I wished I had died.”
#JusticeforJoshKerr
CA: how did you reconcile his statement that he wouldn't harmed himself with his statement about his children?
Frost: I sort of half-reconciled it... That’s why I put him on watch, because I was concerned about that statement…
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Frost: I sort of half-reconciled it... That’s why I put him on watch, because I was concerned about that statement…
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Frost [cont.]: ...but the sincerity of what he said about his children and family was true… he did say it wasn’t his intention to kill himself.
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Josh had disclosed to Frost that he was under the influence of drugs.
Frost: That... was one of the reasons I put him on watch… I know that when they start to come down, they develop paranoia… so that when he was coming down we could look after him...
#JusticeforJoshKerr
Frost: That... was one of the reasons I put him on watch… I know that when they start to come down, they develop paranoia… so that when he was coming down we could look after him...
#JusticeforJoshKerr
CA questions Frost about the JCare file.
Frost, the mental health nurse on duty, explains that he put Josh on a S2 rating after visiting Josh in his cell because he was worried about Josh’s mental health.
#JusticeforJoshKerr
Frost, the mental health nurse on duty, explains that he put Josh on a S2 rating after visiting Josh in his cell because he was worried about Josh’s mental health.
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Stella Gold, Counsel for Aunty Donnis Kerr, is now questioning the witness.
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#JusticeforJoshKerr
Counsel: [D]id you receive training in accessing or managing people who were under the influence of drugs?
Frost: There might have been, I can’t recall.. Most of my learning in assessing people who were on drugs was on site... learning from peers.
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Frost: There might have been, I can’t recall.. Most of my learning in assessing people who were on drugs was on site... learning from peers.
#JusticeforJoshKerr
Counsel: You were asked some questions about whether Josh’s behaviour was likely to escalate or calm down… depending on where he was and how recently in taking drugs. Is it fair to say you don’t have any particular training in that?
Frost: Yes.
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Frost: Yes.
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Frost said he couldn’t understand how Josh didn’t feel the pain from the burns.
Counsel: Is it fair to say that [Josh] was acting erratically?
Frost: Not consistently erratically… he was legible and able to answer my questions.
#JusticeforJoshKerr
Counsel: Is it fair to say that [Josh] was acting erratically?
Frost: Not consistently erratically… he was legible and able to answer my questions.
#JusticeforJoshKerr
Counsel: He had set fire to his cell already. And he is peeling skin off his burnt hands… in your assessment did you consider that he was acting erratically?
Frost: A bit erratically, given that he’s taking the skin off his hands...
#JusticeforJoshKerr
Frost: A bit erratically, given that he’s taking the skin off his hands...
#JusticeforJoshKerr
Counsel: Have you received any training in ‘acute behavioural disturbance’?
Frost: No not really, if I have I’ve forgotten.
C: Would you be aware of treating individuals who are displaying symptoms of ‘acute behavioural disturbance’?
Frost: No, I would just stick w my S1...
Frost: No not really, if I have I’ve forgotten.
C: Would you be aware of treating individuals who are displaying symptoms of ‘acute behavioural disturbance’?
Frost: No, I would just stick w my S1...
Counsel: You prepare interm risk management plan, that is focusing on self harm risk... you wanted to determine whether the fire was a protest or a manifestation of mental health issues.
Frost: It was partly a manifestation of mental health issues caused by the drug...
Frost: It was partly a manifestation of mental health issues caused by the drug...
Counsel: Where would we find that recorded in the internal risk management plan?
Frost: I don’t think I wrote that down.
Q: Did you communicate that with the correctional staff?
F: I think I documented who I spoke to… a health service manager... I can’t recall who it was.
Frost: I don’t think I wrote that down.
Q: Did you communicate that with the correctional staff?
F: I think I documented who I spoke to… a health service manager... I can’t recall who it was.
Counsel: Is it your evidence that the reason for Josh’s behaviour was not just that he’d taken ice, but... his behaviour was also related to a psychiatric state.
Frost: I don’t think I disclosed that… I can’t honestly say… I can’t recall...
#JusticeforJoshKerr
Frost: I don’t think I disclosed that… I can’t honestly say… I can’t recall...
#JusticeforJoshKerr
Counsel: What do these risk management plans contemplate that people do?
Frost: ...the person conducting observations will contact the nurse...
Q: So they are meant to do something other than just write down that they’ve conducted them?...
A: Yes it’s to check on his safety.
Frost: ...the person conducting observations will contact the nurse...
Q: So they are meant to do something other than just write down that they’ve conducted them?...
A: Yes it’s to check on his safety.
Counsel asked what would be expected of somebody who conducts those observations if behaviours of concern are continuing or escalating.
Frost: ...they’ll contact the risk nurse to see if they can help out or resolve the problem; to see if there’s a rise in risk level.
Frost: ...they’ll contact the risk nurse to see if they can help out or resolve the problem; to see if there’s a rise in risk level.
Counsel: So you knew that Josh was Aboriginal?
Frost: Yes
Q: And you’ve noted this down as a ‘risk’ factor?
Frost: Yes, we are trained and advised that Aboriginals… are more at risk than other races... 1/2
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Frost: Yes
Q: And you’ve noted this down as a ‘risk’ factor?
Frost: Yes, we are trained and advised that Aboriginals… are more at risk than other races... 1/2
#JusticeforJoshKerr
Frost [cont.]: ...It’s not very nice being locked in an observation cell.. But if I had raised him to S1, I don’t like doing that... it’s pretty inhumane…
So I didn’t think he was at risk of suicide but wanted to keep observations.
#JusticeforJoshKerr
So I didn’t think he was at risk of suicide but wanted to keep observations.
#JusticeforJoshKerr
Counsel asked how Josh's Aboriginality influenced the risk management plan and supports available.
Q: ...did you consider it part of your role to [contact the Aboriginal Liaison Officer]?
A: I assumed that would happen because he's got Aboriginal heritage.
#JusticeforJoshKerr
Q: ...did you consider it part of your role to [contact the Aboriginal Liaison Officer]?
A: I assumed that would happen because he's got Aboriginal heritage.
#JusticeforJoshKerr
Counsel for Chantel Osman (Josh's girlfriend) asked Frost if he took any steps to see if Josh was taking any medication at the time.
Frost: I assumed I would have, but I can’t recall.
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Frost: I assumed I would have, but I can’t recall.
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Mr Frost is excused as a witness.
Darren Beckett, Supervisor at Port Phillip prison, takes the stand. He describes he was attached to the tactical operations group (TRG), who are a moveable group within the prison, who conduct dynamic operations, searches.
#JusticeforJoshKerr
Darren Beckett, Supervisor at Port Phillip prison, takes the stand. He describes he was attached to the tactical operations group (TRG), who are a moveable group within the prison, who conduct dynamic operations, searches.
#JusticeforJoshKerr
CA asks if the TRG (tactical operations group) are trained to use more significant force than general prisons officers, and Beckett agrees.
Beckett says that the movements of the TRG are determined by the TRG supervisor.
#JusticeforJoshKerr
Beckett says that the movements of the TRG are determined by the TRG supervisor.
#JusticeforJoshKerr
CA: When you first learned of the Code Red, did you know it was related to Josh?
Beckett: No
CA: When did you know?
Beckett: When he came out of the cell and I recognised him from previous dealings… I had come across Josh [before].
#JusticeforJoshKerr
Beckett: No
CA: When did you know?
Beckett: When he came out of the cell and I recognised him from previous dealings… I had come across Josh [before].
#JusticeforJoshKerr
CA: So was it that [supervisor] role that got you involved with Josh's case when the Code Red happened?
Beckett: Yes... I wasn't far from the incident itself. And knowing obviously, sometimes the severity of a Code Red, additional support is needed.
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Beckett: Yes... I wasn't far from the incident itself. And knowing obviously, sometimes the severity of a Code Red, additional support is needed.
#JusticeforJoshKerr
CA: You had a conversation with Josh.
Beckett: Yes.
CA: Do you remember Josh’s demeanour?
Beckett: It was a heightened demeanour… he seemed more heightened and erratic than usual dealings.
#JusticeForJoshKerr
Beckett: Yes.
CA: Do you remember Josh’s demeanour?
Beckett: It was a heightened demeanour… he seemed more heightened and erratic than usual dealings.
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Counsel Assisting: From the body worn camera footage it appears that Josh was quite openly stating that he had used ice.
Beckett: Yes, and it’s not common.
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Beckett: Yes, and it’s not common.
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CA: Did you form any view about why [Josh] had disclosed using ice?
Beckett: My thought is that he would probably have been a bit scared about the effects, and was trying to get help… He wasn’t worried about repercussions, but trying to get help.
#JusticeForJoshKerr
Beckett: My thought is that he would probably have been a bit scared about the effects, and was trying to get help… He wasn’t worried about repercussions, but trying to get help.
#JusticeForJoshKerr
CA: What could you see of his physical injuries and how they were affecting him?
Beckett: His movement was a bit more erratic, his arms were moving a lot more, he seemed to be unable to sit still. He seemed to be coping quite well...
#JusticeforJoshKerr
Beckett: His movement was a bit more erratic, his arms were moving a lot more, he seemed to be unable to sit still. He seemed to be coping quite well...
#JusticeforJoshKerr
CA: Was it your job to assess Josh’s wellbeing?
Beckett: No.
CA: Whose role would that have been?
Beckett: St Vincent’s.
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Beckett: No.
CA: Whose role would that have been?
Beckett: St Vincent’s.
#JusticeforJoshKerr
*In above tweets the tactical operations group abbreviation was incorrectly written as 'TRG' but it is 'TOG'. Apologies for confusion.
CA: [When Josh was placed in the medical unit] there was a directive given - and there's some lack of clarity at the moment... that there was a directive given that Josh's cell door could only be opened if the TOG would present.
Beckett: Yes I am aware of it.
#JusticeForJoshKerr
Beckett: Yes I am aware of it.
#JusticeForJoshKerr
CA: In what circumstances would this directive be given?
Beckett: If the safety of the officers in the unit could be compromised.
Q: Who would give the directive?
A: It would be in consultation w the manager & TOG supervisor. Generally the directive would come from Duty Manager.
Beckett: If the safety of the officers in the unit could be compromised.
Q: Who would give the directive?
A: It would be in consultation w the manager & TOG supervisor. Generally the directive would come from Duty Manager.
CA: In your experience, in what circumstances could help staff and or correctional staff [override this directive] to get the door open?
A: If there is potential for a life threatening incident or if there was obviously the threat of life or self harm.
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A: If there is potential for a life threatening incident or if there was obviously the threat of life or self harm.
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The witness is excused and court has adjourned for lunch until 2pm.
#JusticeForJoshKerr
#JusticeForJoshKerr
Court resumes after lunch.
The next witness called to give evidence is Supervisor Karen Gibson.
You can join the livestream here:
#JusticeForJoshKerrcsvic.webex.com/wbxmjs/joinser…
The next witness called to give evidence is Supervisor Karen Gibson.
You can join the livestream here:
#JusticeForJoshKerrcsvic.webex.com/wbxmjs/joinser…
Counsel Assisting begins questioning.
Q: As of August 2022 where did you work?
A: Port Phillip Prison
Q: What was the role you had there?
A: I was a supervisor.
#JusticeForJoshKerr
Q: As of August 2022 where did you work?
A: Port Phillip Prison
Q: What was the role you had there?
A: I was a supervisor.
#JusticeForJoshKerr
Q: You were engaged as supervisor at Port Phillip Prison, what did the role of supervisor involve?
A: So the responsibility of the running of a unit, the safety of my staff, prisoners and reacting to the days events in a professional manner.
#JusticeForJoshKerr
A: So the responsibility of the running of a unit, the safety of my staff, prisoners and reacting to the days events in a professional manner.
#JusticeForJoshKerr
CA: When did you first know that code red related to fire in Josh’s cell?
A: ...When I attended the unit I was talking to one of my officers there. He took a phone call and was alerted that there was an alarm going off in a cell...I saw the flames under the cell door.
A: ...When I attended the unit I was talking to one of my officers there. He took a phone call and was alerted that there was an alarm going off in a cell...I saw the flames under the cell door.
Q: Looking at your statement, you first had the opportunity to see Josh after he was brought into the matilda east “chook pen” in the east yard?
A: Yes
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A: Yes
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CA: What did you see [Josh] doing and how did you see him behaving?
A: Josh was very alert, he was very heightened at the time. I did try to get his attention. I asked him if he was okay. He seemed to just look straight through me. He looked at me, but he just looked through me.
A: Josh was very alert, he was very heightened at the time. I did try to get his attention. I asked him if he was okay. He seemed to just look straight through me. He looked at me, but he just looked through me.
CA: Did you get the opportunity to see for yourself while you were in [Josh’s] presence to see what his injuries were?
A: I saw burnt hands and arms and a bit of skin coming from his arms. It was quite distressing.
#JusticeForJoshKerr
A: I saw burnt hands and arms and a bit of skin coming from his arms. It was quite distressing.
#JusticeForJoshKerr
Q: You refer to steps that you took because you knew Josh to be Aboriginal, what did you do?
A: I contacted the Aboriginal Liaison Officer. I tried to radio him. I had no response. So I sent them an email to make him aware that Josh had been in a fire & was injured & distressed
A: I contacted the Aboriginal Liaison Officer. I tried to radio him. I had no response. So I sent them an email to make him aware that Josh had been in a fire & was injured & distressed
Counsel Assisting refers the witness to review the Interim Management Plan.
Q: As you read it, what instructions does that give about how and when to monitor josh?
A: Every 30 to 60 minutes.
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Q: As you read it, what instructions does that give about how and when to monitor josh?
A: Every 30 to 60 minutes.
#JusticeForJoshKerr
Q: What form should observations take?
A: Observation every 30 minutes
Q: Is this by CCTV or entering the cell? Or is it at the discretion of officers?
A: Not stated…sorry it does say CCTV monitoring
#JusticeForJoshKerr
A: Observation every 30 minutes
Q: Is this by CCTV or entering the cell? Or is it at the discretion of officers?
A: Not stated…sorry it does say CCTV monitoring
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Q: As you sit her today, what can you recall about the way that Josh was presenting or behaving?
A: I recall him pacing and being quite busy in the head, quite heightened and quite erratic.
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A: I recall him pacing and being quite busy in the head, quite heightened and quite erratic.
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Q: Are you able to recall whether he had clothes on?
A: I don't recall.
Q: Are you able to recall whether he was wet?
A: No I don’t recall.
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A: I don't recall.
Q: Are you able to recall whether he was wet?
A: No I don’t recall.
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Q: At para 23 of your statement, you refer to a convo that you had with a CO who said to you “Josh is fucking all over the place”. What did you take him to mean when he said that?
A: Exactly what I saw. I know this CO & I understand the way he speaks....[Josh] was being erratic.
A: Exactly what I saw. I know this CO & I understand the way he speaks....[Josh] was being erratic.
Q: Do you recall being told anything about a requirement that Josh’s cell only be opened if the Tactical Operations Group are present?
A: No
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A: No
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Q: Once a directive is given [that a cell can only be open if TOG is present], can people appeal that? If people feel theres a need...?
A: Anyone has the right to say yes or no, but… I’ve never known anyone who has disagreed with that form of directive
#JusticeForJoshKerr
A: Anyone has the right to say yes or no, but… I’ve never known anyone who has disagreed with that form of directive
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Q: Were you given any training about how to deal with prisoners on drugs, particularly relevant to this case, people using amphetamines?
A: No, not that I can recall.
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A: No, not that I can recall.
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Q: From your perspective as the corrections supervisor… what did you understand your role to be [if someone was using drugs]?
A: To look after their welfare, to contact medical. If it was severe to call a code black and medical would take over.
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A: To look after their welfare, to contact medical. If it was severe to call a code black and medical would take over.
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Q: How did you assess if someone’s behaviour was severe enough to call a code black?
A: Speak to them, see if they can communicate with us. See if they are vomiting or not feeling well.
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A: Speak to them, see if they can communicate with us. See if they are vomiting or not feeling well.
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Q: You are aware [Josh] went to hospital, that he came back to hospital and you wanted to go check on him because you were concerned about him.
A: Yes definitely. He was one of my prisoners I was in charge of for the day. I take pride in looking after my prisoners and my staff.
A: Yes definitely. He was one of my prisoners I was in charge of for the day. I take pride in looking after my prisoners and my staff.
Q: There's evidence [Josh] wasn’t medically discharged but [brought back to Port Phillip Prison] due to behavioural issues… when you went to see him in St Johns, did you have any idea of this?
A: No.
Q: Did you assume he had been medically discharged from the hospital?
A: Yes.
A: No.
Q: Did you assume he had been medically discharged from the hospital?
A: Yes.
Counsel for Aunty Donnis Kerr shows the G4S Operational Instructions for at risk prisoners to the witness.
Q: This document says...for any prisoner deemed to be at risk...CCTV may be used to supplement but not replace direct observation… is that news to you?
A: Yes
Q: This document says...for any prisoner deemed to be at risk...CCTV may be used to supplement but not replace direct observation… is that news to you?
A: Yes
Counsel for St Vincent's questions Supervisor Karen Gibson.
Q: Did you take the worries you had and report them to any Corrections staff or any St Vincent’s staff?
A: No
Q: ...those observations weren’t sufficiently serious to report to Corrections or St Vincents staff?
A: No.
Q: Did you take the worries you had and report them to any Corrections staff or any St Vincent’s staff?
A: No
Q: ...those observations weren’t sufficiently serious to report to Corrections or St Vincents staff?
A: No.
Counsel for G4S questions Supervisor Karen Gibson.
Q: Why did you not report [concerns] to any other staff?
A: I did not think it was necessary as he was in the appropriate hands.
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Q: Why did you not report [concerns] to any other staff?
A: I did not think it was necessary as he was in the appropriate hands.
#JusticeForJoshKerr
The witness was excused and court adjourns for the day.
The inquest will resume tomorrow morning at 10am.
We encourage community members to head down to the coroner's court and show their support for Josh's family.
#JusticeforJoshKerr
The inquest will resume tomorrow morning at 10am.
We encourage community members to head down to the coroner's court and show their support for Josh's family.
#JusticeforJoshKerr
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