Five key findings from the NT coroner's inquest into Kumanjayi Walker's death in police custody

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In her 683-page report, Coroner Elisabeth Armitage made 32 formal recommendations for change, after an almost three-year coronial inquest into the police shooting of 19-year-old Warlpiri-Luritja man Kumanjayi Walker.
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains the name and image of an Indigenous person who has died, used with the permission of their family.
This story contains racist and offensive language and images, as well as references to sexual assault.
The coroner made findings about Kumanjayi Walker's upbringing in remote central Australia, plagued by poverty and health issues, as well as his struggle to cope at school, because of his disabilities.
Mr Walker was deaf in one ear and was likely born with fetal alcohol spectrum disorder (FASD).
"From the age of 13 to 18, Kumanjayi spent a considerable period of time in juvenile detention or under some restraint, such as bail or subject to a court order," Judge Armitage said.
The coroner also explored Zachary Rolfe's background; his previous career in the military and prior uses of force.
Through examination of his text messages, she found the use of racial slurs was "normalised" between officers.
"The purpose of receiving this evidence was to investigate whether Mr Rolfe held racist views, what the consequence of those views might have been for his conduct on 9 November 2019, why he might have held those views and how they might be prevented in the future," she wrote.
Here are five of the key findings in the report.
Ultimately, Judge Armitage found Kumanjayi Walker's death was "avoidable" and the failed arrest of the 19-year-old was "a case of officer induced jeopardy".
"[It's] an expression that describes situations where officers needlessly put themselves in danger," Judge Armitage wrote.
The coroner found Mr Rolfe, "a very junior officer" did not prioritise safety in the arrest of a "vulnerable teenager", such as Mr Walker, and made a series of "flawed decisions that significantly increased the risk of a fatal interaction with a member of the public".
Local Yuendumu Sergeant, Julie Frost, had devised a so-called "5am arrest plan", to effect a safe arrest of Mr Walker in the early hours of November 10, in the presence of a local officer who knew him.
Mr Walker was wanted for allegedly breaching a court order, and days before his death, threatening two other police officers with an axe.
But the coroner found Mr Rolfe "jettisoned" the 5am arrest plan — which Judge Armitage also found "was not without its weaknesses" — and substituted a "vastly inferior approach" which ended in Mr Walker's death.
Judge Armitage found that she could not definitively rule that Zachary Rolfe's racist attitudes contributed to Kumanjayi Walker's death, however she also said it could not be ruled out.
"That I cannot exclude that possibility is a tragedy for Kumanjayi's family and community who will always believe that racism played an integral part in Kumanjayi's death," Judge Armitage said.
Judge Armitage said that Mr Rolfe's text messages provided evidence of his "derisive attitude to female colleagues and some superiors".
She also noted that the messages revealed his "attraction to high adrenaline policing; and his contempt for 'bush cops' or remote policing; all of which had the potential to increase the likelihood of a fatal encounter with Kumanjayi".
The coroner found his "unsavoury views" were consciously or unconsciously embedded in the decisions he made on the night Mr Walker was shot in Yuendumu.
The inquest reviewed a string of previously unseen body-worn camera videos of arrests made by Mr Rolfe prior to Kumanjayi Walker's death.
Some of them had been ruled inadmissible in the jury trial which acquitted the former officer of murder, manslaughter and engaging in a violent act causing death.
The coroner found, based on that evidence, there were at least five occasions that Mr Rolfe used "unnecessary force" and that he had a "tendency to rush into situations to 'get his man', without regard for his and others' safety, and in disregard of his training".
"There were instances where Mr Rolfe used force without proper regard for the risk of injury to persons, all of whom were Aboriginal boys or men, and significant injuries were caused to suspects because of his use of force.
"When this evidence is considered together with the contempt Mr Rolfe showed for the hands-off approach of Officers Hand and Smith on 6 November 2019 [when Mr Walker threatened them with an axe], it points to Mr Rolfe prioritising a show of force over potential peaceful resolutions," the coroner found.
The coroner noted "disturbing evidence" that Mr Rolfe had, on several occasions, recorded and shared videos of his uses of force during arrests.
"It is clear that a significant motivation for doing so was because he was proud of, was boasting about, and wished to be celebrated for, his physical feats of tactical skill or ability," the coroner wrote.
Coroner Elisabeth Armitage said the evidence she gathered over almost three years showed that Zachary Rolfe was not a "bad apple", but instead "the beneficiary of an organisation with hallmarks of institutional racism".
"To be clear, many of the police officers who gave evidence to the Inquest, impressed me as curious and culturally sensitive officers who had dedicated their working lives to serving the largely Aboriginal communities they were tasked to police," the coroner found.
However, after a series of "grotesque" racist mock awards were revealed at the inquest — handed out at Christmas parties by the force's most elite tactical unit — the coroner found racism was widespread.
"That no police member who knew of these awards reported them, is, in my view, clear evidence of entrenched, systemic and structural racism within the NT Police," she wrote.
Just hours before Kumanjayi Walker was shot, Yuendumu's local nurses had evacuated the community, fearing for their safety after a string of break-ins at their living quarters.
The coroner said she was not critical of their decision to leave, but made recommendations that NT Health improve its withdrawal processes, to make it clearer to community when staff intended to leave.
With no nurses in the community, Kumanjayi Walker was taken to the police station after the shooting — where he died on the floor of a police cell after receiving first aid from the officers.
"After Kumanjayi was shot, the fact that there was no operational local Health Clinic to treat him, exacerbated the trauma," the coroner wrote.
"Despite the suspicion of some members of the community, there was no collusion or pre-planning between NT Health and NT Police concerning the withdrawal of clinic staff from Yuendumu.
"To the contrary, there was a lack of communication between Health and Police and little awareness about what the other was doing in response to the apparently targeted break-ins."
The coroner found by the time Kumanjayi Walker passed away on November 9 2019, the medical retrieval flight had not yet left Alice Springs.
"In those circumstances, even if the clinic had remained open, there was no possibility of his survival."
The inquest's findings and formal recommendations are available in full here.