A NSW coroner who investigated the death in custody of a Stolen Generations member has criticized plans to delay health checks for Indigenous inmates, saying it could lead to problems being overlooked.
Gregory Merriman, a 58-year-old Yuin man and direct descendant of revered Yuin leader Umbarra, died at the Silverwater Metropolitan Reception and Detention Center (MRRC) in Sydney’s western suburbs in December 2022.
In findings handed down on Friday, New South Wales deputy state coroner Harriet Grahame said Merriman was found unconscious in his cell 30 minutes after being exposed to CS spray (tear gas) sprayed by prison officers trying to contain a fight in a common area of the prison. Merriman was not involved in the fight and appeared on CCTV footage to have made “verbal attempts to calm the others”, the coroner said.
When a nurse checked on Merriman in his cell a half-hour later, as part of a wellness check being conducted on all prisoners exposed to CS spray, she found him lying on the floor unresponsive.
The autopsy revealed that he had suffered an acute myocardial infarction caused by ischemic heart disease.
In his 60-page findings, Grahame said Merriman’s heart disease was asymptomatic but that opportunities had been missed to improve his care, such as starting statins to control his slightly elevated cholesterol.
He expressed concern that preventive health screening policy changes made since his death could mean more cases could go undetected.
“The gap (between the health outcomes of Indigenous and non-Indigenous Australians) has not closed,” he said. “In this context, the importance of health screenings and culturally safe care for all First Nations inmates cannot be underestimated.”
At the time of Merriman’s death, all Aboriginal prisoners aged 45 and over were required to be screened for chronic illnesses within 30 days of their initial health screening in prison, called a reception screening assessment (RSA). Merriman had not been screened for chronic illnesses, which Grahame said was “not consistent with policy.”
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Since then, he said, the policy has been revised to require a chronic health exam (now called a chronic health assessment) for all patients who have an identified chronic condition. All Aboriginal prisoners without an identified chronic health condition and non-Aboriginal people over the age of 55 must undergo a Preventive Health Screening (PHS) within 12 months of their RSA.
Grahame said she was “very concerned about the new time frame.”
“Performing proper health screenings is one of the few positive outcomes possible for those who are incarcerated,” he said. “Many Aboriginal prisoners are serving short sentences. If the PHS is held towards the end of the 12-month period, many prisoners will be released before it is carried out. I am concerned that the new policy will constitute a decline in the level of service rather than a clear improvement.”
However, Grahame declined to make recommendations directed at Justice Health and instead recommended that the commissioner of custodial services update its policies on the use of CS spray to improve the first aid response for prisoners exposed to the gas.
He also addressed Merriman’s family and said the over-incarceration of First Nations people was the root cause of the persistently high number of deaths in custody.
“I accept that this issue is based on the current effects of colonization,” he said. “Until the broader causes of over-representation are adequately addressed, the disproportionate number of deaths in First Nations custody will not be reduced.”
Graheme also pointed to an open letter written by the state coroner in October, which said New South Wales had recorded the highest number of Indigenous deaths in custody in its history – 12 people died in 2025.
This came at the end of a five-year period in which the number of Aboriginal people in custody increased by 18.9%, while the number of non-Aboriginal prisoners decreased by 12.5% and the number of Aboriginal people on remand increased by 63%.
“These figures reflect – consistent with the sentiments expressed by Greg’s family – that the entrenched over-representation of First Nations people in the criminal justice system is a systemic problem.”
