Warning: this story contains the name and image of a person who has died, and disturbing details.

Independent senator Lidia Thorpe has criticised the coronial findings on the death of Yorta Yorta and Gunaikurnai man Joshua Kerr, whose death was found to be a "preventable tragedy".

On Monday, Coroner David Ryan found Mr Kerr's death on August 10 2022 was likely preventable, after he died as a result of drugs in his system.

His death came in the aftermath of having his escort to St Vincent's Hospital in Narrm cancelled by Tactical Operations Group (TOG) members - without medical staff knowing - while suffering from severe burns to his hand and acute behavioural disturbance (ABD) as a result of methamphetamine use.

Having returned to the privately-run Port Phillip Prison, Mr Kerr died in his cell while staff watched on, having been instructed by TOG to not enter his cell without their permission.

"Josh would have very likely survived had he remained in hospital," Mr Ryan said on Monday.

The court heard staff witnessed on CCTV Mr Kerr call out "I'm dying," with Mr Ryan finding: "There were a number of periods of time on 10 August 2022 where more decisive, considered and effective action by staff would have altered the care and treatment received by Josh in a way that most likely would have prevented his passing."

Furthermore, he said the case saw a "disproportionate focus on security concerns," and argued "TOG directions should not prevent a prisoner from receiving medical treatment".

On Wednesday, Senator Thorpe, a Gunnai, Gunditjmara and Djab Wurring woman, took to social media to criticise the term "preventable" in the context of the death of her cousin.

"Deaths in custody are always preventable," Ms Thorpe said.

"The ongoing lack of action from governments shows a clear lack of value placed on First Peoples' lives in this country."

There have been at least 568 Indigenous deaths in custody since the Royal Commission into Aboriginal Deaths in Custody brought down its findings in 1991 — including nine in 2024 to date.

2022-2023 saw the highest number of Indigenous deaths in custody since records began, with 21 First Nations prisoners dying whilst incarcerated — 11 of them unsentenced.

"Not one person has been held accountable for a death in custody in this country, and once again, no one has been found responsible for Josh's death," Senator Thorpe said.

"This country needs Truth-telling and Labor needs to urgently take action on implementing the recommendations from the Royal Commission into Aboriginal Deaths in Custody.

"I will continue to push until we see change and justice for our people. Enough is enough."

@natindigtimes The death of a 32-year-old Indigenous man who died in his cell as staff watched due to flawed protocols has been labelled a "preventable tragedy" by the coroner. Mr Kerr's mother, Donnas Kerr, criticised the prison staff's neglect, highlighting systemic failures and calling for serious attention to preventable Aboriginal deaths in custody. #justiceforjoshkerr #indigenousaustralia #aboriginalaustralia #aboriginaldeathsincustody ♬ original sound - National Indigenous Times

Speaking outside of the Coroners Court on Monday, Mr Kerr's mother, Aunty Donna Kerr, noted the preventable nature of her sons death, asking: "How many times do we have to hear these words before we take Aboriginal deaths in custody seriously?"

"The coroner found that the Correctional and medical staff at the prison should have known my son was dying. For hours, they didn't call, even go into his cell, or call an ambulance," she said.

"This is what is wrong with our system - the lack of care and compassion for human life, for Aboriginal lives."

Robinson Gill's Principal Lawyer, Ali Besiroglu, who had represented the family through the inquest, confirmed to National Indigenous Times that the firm will commence a civil action on behalf of the Kerr family against those responsible for the circumstances surrounding Mr Kerr's death.

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