A coronial inquest into the death of an Aboriginal man who was forcibly removed from his family as a child and spent his life in institutions says his case "brings great shame on white Australia".
Warning: Aboriginal and Torres Strait Islander readers are advised that the following story contains the name and image of a person who has died.
Kevin Bugmy, 57, died of a heart attack alone in his cell at the Cessnock Correctional Centre in April 2019.
Mr Bugmy, a Barkandji man from western New South Wales, was taken from his family as a child and placed in foster homes and institutions.
He suffered from chronic substance use.
Deputy state coroner Harriet Grahame found the care Mr Bugmy received for solvent use "over many years was grossly inadequate".
She noted his inhalant use was well-known "at an institutional level", but "it became clear that this knowledge was not properly passed on to relevant operational staff at Cessnock Correctional Centre".
The court had heard Mr Bugmy had at least 15 instances of inhalant abuse recorded against him before he arrived at Cessnock Jail in December 2018.
Magistrate Grahame said his death "highlights the role of inter-generational trauma in the over-representation of First Nations people in custody".
"A member of the Stolen Generation[s], separated from his family and raised in foster homes and institutions," her findings began.
"His story is one that brings great shame on white Australia."
Mr Bugmy was serving a life sentence for murder and was eligible for parole in 2000.
"Kevin was held in continuous custody for 36 years for an offence he had committed at just 20 years of age," Magistrate Grahame said.
"He was continually refused release without ever being offered appropriate case management for issues that had been clearly identified for decades."
Magistrate Grahame said Mr Bugmy was never offered culturally safe help with his solvent use, and the parole system had failed him.
"One cannot help but wonder how many long-term prisoners like Kevin are denied parole over decades, without ever having been provided adequate and culturally safe case management," she said.
"Kevin may have been 'institutionalised' by the time of his death, but it must not be forgotten that Kevin was never offered a specific program to counter his particular and chronic solvent use issues."
She recommended Corrective Services NSW implement a range of appropriate programs, including an Aboriginal-specific drug and alcohol program, saying she was "astounded" one did not already exist.
Corrective Services should also review its policies into prisoner transfers after Mr Bugmy was moved 50 times over 19 years.
The coroner said "excessive interfacility transfers may be inhumane" and "may exacerbate social and family dislocation, health issues and cultural disconnection".
Aboriginal Legal Service lawyer Jalal Razi is representing Mr Bugmy's family.
He said the "institutionalisation and deficient health care that contributed to Mr Bugmy's death are still putting prisoners' lives at risk".
"No-one should die in a prison cell alone, in pain, terrified and separated from their loved ones, yet this is the reality of for far too many Aboriginal and their families are left with that painful legacy for generations to come," he said.
"Mr Bugmy's family and other families we represent are waiting to see a coronial system with more teeth that can hold the powerful to account and can create real change."
Magistrate Grahame — who kept a picture of Mr Bugmy in her office during the inquest — also accepted the view of his sister, Doreen Webster, that his inability to get parole became intertwined with his substance abuse.
Ms Webster only met her brother as an adult.
"I was so happy to see him … we just hugged and hugged and we clicked straight away," she said outside court.
Her four brothers, including Mr Bugmy, have now all passed.
"When Kevin died, he was alone without his family there, only his prison mates. Throughout Kevin's 57 years, the state took away the things that mattered most. His family, his freedom, his hope. And finally, his life," she said.
"To them, Kevin is just another statistic. Another Black death in custody."
