New South Wales Deputy State Coroner Harriet Grahame has released findings from an inquest into the death of Gregory Merriman, a 58-year-old Yuin man and direct descendant of revered Yuin leader Umbarra, who died at the Metropolitan Reception and Remand Centre (MRRC) in Sydney in December 2022. In her findings handed down on Friday, Grahame stated that Merriman was found unresponsive in his cell 30 minutes after being exposed to CS spray (tear gas) deployed by prison officers to contain a fight in a common area of the facility.

The coroner noted that Merriman was not involved in the altercation and appeared on CCTV footage to have made "verbal attempts to calm others." A nurse conducting welfare checks on all prisoners exposed to the gas found him lying unresponsive on the floor of his cell half an hour later. An autopsy revealed he died from an acute myocardial infarction caused by ischemic heart disease. In her 60-page report, Grahame highlighted that Merriman's heart disease was asymptomatic, but opportunities to enhance his care, such as initiating statin therapy for slightly elevated cholesterol, had been missed.

Grahame raised concerns that policy changes to preventative health screenings implemented since his death could lead to more cases being overlooked. She remarked, "The gap [in health outcomes between Indigenous and non-Indigenous Australians] has not closed. In this context, the importance of health screening and culturally safe care for all First Nations inmates cannot be overstated." At the time of Merriman's death, all Aboriginal inmates aged 45 and over were required to undergo a chronic disease screening within 30 days of their initial reception screening assessment (RSA) in prison, but Merriman had not received this, which Grahame said "was not consistent with policy."

The coroner explained that the policy has since been revised to mandate a chronic health assessment for all patients with an identified chronic condition, while all Aboriginal prisoners without a chronic condition and non-Aboriginal individuals over 55 are to receive a preventative health screening (PHS) within 12 months of their RSA. Grahame expressed being "very troubled by the new time frame," stating, "The provision of adequate health screening is one of the very few possible positive outcomes for those who are incarcerated. Many Aboriginal inmates serve short sentences. If PHS is set to occur towards the end of the 12-month window, many inmates will be released before it takes place. I am concerned the new policy constitutes a decrease in the level of service rather than a clear improvement."

However, Grahame declined to make recommendations directed at Justice Health, instead advising the commissioner of custodial services to update policies on CS spray use to improve first aid responses for exposed prisoners. She also addressed Merriman's family, asserting that the over-incarceration of First Nations people is the root cause of persistently high deaths in custody: "I accept that this issue is grounded in the ongoing effects of colonisation. 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 noted that NSW recorded its highest-ever number of Indigenous deaths in custody, with 12 fatalities in 2025. This occurred at the end of a five-year period where the Aboriginal prison population increased by 18.9%, while non-Aboriginal prisoners decreased by 12.5%, and Aboriginal remand numbers surged by 63%.

Source: www.theguardian.com