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Counsel for the family submitted that greater observation of prisoners was needed.
The Coroner noted that supervision needs to conform with individual circumstances.
On Saturday 21 October 1989 at about 8pm the deceased complained of a headache and earache which had apparently started the day before.She gave him advice as to the illness and provided him with medication.He later approached another nurse and said he wanted to return to his cell.The Aboriginal Legal Service argued that the deceased was depressed, angry and dispirited as a result of the regime at Endeavour House.There was no full-time psychologist, counsellor or youth welfare worker. For example, there were no toilet facilities, only buckets and pans.He found the supervision to be appropriate in this case.