On the 29th of December 2015, a twenty six year old Dunghutti man named David Dungay Junior was in the mental health ward of Long Bay Prison Hospital in Sydney. He had a packet of biscuits and rice crackers. He was eating them.

Prison staff told him to stop because of his diabetes. He refused. Six members of the Immediate Action Team were called. They moved him to a different cell, held him face down on the bed, and injected him with a sedative.

Throughout this, David Dungay Jr said the words I cannot breathe. He said them twelve times. An officer responded: if you can talk, you can breathe.

Minutes later, he was unresponsive. He was pronounced dead shortly after. He was twenty six years old. He was three weeks from being considered for release.

This episode tells the full story of David Dungay Jr, a proud Dunghutti man from Kempsey who deserved better from every system that was supposed to keep him safe. We talk about who he was before the circumstances of his death swallowed that. We talk about the Immediate Action Team officers who held him down, most of whom had received no training in the risks of restraining someone face down for an extended period, a risk that had been documented in the medical literature for years and flagged specifically in Royal Commission recommendations made twenty four years earlier.

We talk about the coronial inquest that took four years to deliver findings of systemic failure, and then recommended no disciplinary action against any officer involved. We talk about his mother Leetona Dungay, who has stood in front of crowds of tens of thousands, taken her son's case to the United Nations, and refused to let the word systemic be the last word on what happened to her son.

And we talk about what it means that this country had already been told, in writing, exactly how to prevent this, and still let it happen.

This podcast is recorded on Wadjuk Nyoongar Country. We acknowledge the Wadjuk Nyoongar people as the Traditional Custodians of the land this show is made on, and pay our respects to their Elders, past and present.

This is a 3 Brothers Production.