The probable search area was within 10 kilometres to the and south and about 4 kilometres to the east and west to the high point of the mountain ranges; The most likely location was within 2 kilometres and certainly within 10 kilometres of where he was last seen; was limited information as to the reason for his disappearance; He had gone missing on one prior occasion. He was located in the area to the east known as Katjikuta; He was for by the reporting person, Sylvia Ken; He had a diminished brain capacity; Although he had a diminished brain capacity, he did know when to eat and drink; Water was available in the region due to recent rain falls; He knew the area; His medication was not health related; He had previous medical conditions, namely epilepsy and pneumonia; Local community trackers tried and were unable to locate his tracks due to the heavy rain fall on Saturday 20th; He was physically impaired however, was able to walk faster than the reporting person; He had no equipment with him; The temperature on Friday 19th was about 42 degrees Celsius, Saturday 20th was about 38 degrees Celsius and Sunday 21st was about 30 degrees Celsius. The minimum temperatures were about 25 degrees Celsius; The likelihood that he had left the area by vehicle was slim. The Community Constable advised that community members would not pick him up due to his behaviour; The area west of Amata Community to the mountain ranges is secret men’s and secret women’s land. This area basically forms a semi circle from the North through to the South. Searching these areas required liasing with community elders and utilising the assistance of the community;
'Acute psychosis – secondary to petrol sniffing +/- pneumonia.' (Exhibit CK1d) He was procaine and haloperidol, both intramuscularly. From that time onwards, the progress notes are littered with attendances at both Amata and Pipalyatjara clinics in an agitated or psychotic state. For example, on 21 October 1991 the notes record: '4pm – brought to clinic by police handcuffed – fitting.' (Exhibit CK1d) On 12 December 1996 Kunmanara Ken was seen by Dr Kerrie Gell, who is now the Senior Medical Officer for the Nganampa Health Council. Dr Gell recorded: 'Horrible situation. (Kunmanara) Ken now aged 29 years Principal history probably at Amata Notes record: fitting with witnessed generalised seizures Abnormal behaviour Premorbid state prior to petrol sniffing not recorded Will sniff occasionally now if has opportunity Now behaviour pattern is: Episodes of uncontrollable anger which seem unpredictable, with threatening behaviour and sometimes injuries to family or others; Frightening children/sometimes according to mother triggered by children teasing him; These occurrences seem almost daily; Generalised seizures – frequency unclear, less than one per week or but surprisingly one happened today while we were at Watami; Typical, brief (less than 2 minutes) followed by very disturbed wandering postictal behaviour with threats; Sometimes nocturnal wandering which may be prompted by seizures – not sure. This young man requires 24 hour per day supervision by parents. Assessment: Unable to examine him today – maybe possible with Brenton (father) there. I would think that he may have complex partial epilepsy (anger + behavioural manifestations) with generalisation generalised seizure (frontal or temporal lobe focus). Other possibilities include hyper thalamic lesions (rage reactions) with intercurrent generalised seizures or personality disorder/intellectual disability with epilepsy. This is going to be hard to sort out. Any investigations or even respite for family will be difficult in this aggressive, large man.' (Exhibit CK1d)
'The lack of a border scheduling (detention) arrangement actually makes cross border transport illegal and continues to be a major impediment to the safe management of these patients. There appears to be recent action by the Department of Human Services in South Australia to correct this problem.' (Exhibit C12, paragraph 6.2.1) South Australian law requires that detention may only be ordered by a Medical Practitioner, which is often impractical on the Anangu Pitjantjatjara Lands. Dr Torzillo commented: 'In our view the only way this could be overcome is that following discussion with a responsible Medical Officer for Nganampa Health Council, the Psychiatrist on-call for the Rural and Remote Psychiatry service (in Adelaide) is actually able to write a schedule (detention order) for the patient so as to initiate their transfer.' (Exhibit C12) I have mentioned these issues because they are relevant not only to the deaths of Kunmanara Ryan and Kunmanara Cooper, but possibly also to the other examples of self-harming behaviour which have been displayed on the Anangu Pitjantjatjara Lands in the last 18 months or so. Conclusions Clearly, there is room for improvement in the standard of mental health services on the Anangu Pitjantjatjara Lands, even though improvements have already been made. It is not possible for me to conclude, on the basis of the evidence before me, that the absence of psychiatric services on the Anangu Pitjantjatjara Lands had a direct causal relationship with any of the deaths before me. In particular: Kunmanara Ryan received periodic consultant psychiatric treatment from Dr Cord-Udy during 2003, and on the last occasion he gave no indication that he was suicidal or otherwise intent upon harming himself. On that basis, it cannot be argued that Kunmanara Ryan received a level of treatment which was less than that which might be expected in the metropolitan area of Adelaide (assuming that is the criterion), and it has not been established that a lack of psychiatric services played a part in Kunmanara Ryan’s death. Similarly, although there were difficulties during Kunmanara Cooper’s imprisonment both in Port Augusta and at James Nash House in Adelaide, he was