Michael Suckling was a proud Aboriginal man and loving father, brother and son. Michael was known for his sense of humour and loved having a laugh with his family and mates. Michael enjoyed being active outdoors. Michael tragically died at Ravenhall Prison on 7 March 2021 leaving his family, friends and community devastated.

On 24 February 2023 the Coronial Inquest into Michael’s passing began and closely examined the adequacy and cultural appropriateness of healthcare provided to Michael in prison, as well as the conditions of his imprisonment.

Most concerningly the Court heard Michael weighed 199 kilograms when he died in 2021 despite weighing just 82 kilograms in 2018 when he was first taken into custody.

After more than one year and nine months after the inquest began, Coroner Peterson handed down her findings on 13 December 2024 bringing the family’s long wait for answers to a close.

The Coroner found that Michael endured a range of interconnected health problems in prison, including weight gain, chronic pain, mobility issues, and the decline of his mental health. Despite Michael experiencing many of these issues for the first time in prison, the Coroner found that the medical response to Michael’s weight gain was “ad hoc and perfunctory”, and the medical treatment he received was fragmented.

The Coroner found that more could have been done for Michael if his healthcare had been “trauma-informed, holistic and person-centred”. Ultimately, the Coroner found that Michael’s weight gain contributed to his passing.

Victorian prisons have been found yet again to be places of significant harm and suffering for our people. The Coroners Court is currently investigating the passing of other Aboriginal people in prison custody and all of them involve questions around the quality of healthcare they were provided in Victoria’s prisons. At least two other coronial inquests involve an Aboriginal person rapidly gaining weight in prison, and that weight gain going untreated and unaddressed.

The Victorian Government needs to urgently act to ensure Aboriginal people should be safe in custody and receive culturally safe heath care, delivered by Aboriginal Community Controlled Health Organisations (ACCHOs) while in custody. Coroner Peterson saw that it is “critical that Victoria’s prison system and allied services provide the highest level of culturally appropriate care and treatment and accommodate holistic and culturally responsive approaches.”

Coroner Peterson supported the call to end the use of private healthcare providers in the prison system in favour of the Government contracting ACCHOs directly to deliver prison healthcare services for Aboriginal people. She recommended the Victorian Government look into how ACCHOs can provide their services to Aboriginal people in prison in the interim.

Michael’s family held concerns about his treatment in prison and the impact of lockdowns, program delivery and COVID-19 on his health. The Coroner also commented on the effect that these had on Michael’s physical and mental health and the treatment he received.  

Prison healthcare was a central focus of the Coroner’s findings into the passing of Veronica Nelson, which were handed down at the end of January. The Victorian Government announced it would transition from private healthcare to public healthcare in women’s prisons in response to the Inquest and whilst this was a welcome move this must extend across to the entirety of the prison system.

VALS and other ACCOs have consistently called for prison healthcare to be delivered by ACCHOs and the end of privatised prison healthcare.

Quotes Attributable to Maree Brincat, Michael Suckling’s mother:

“My son Michael was dearly loved. I remember him as a social person who loved the outdoors, loved to cook, and who looked after his health and appearance.”

“I miss him constantly and in losing him, I feel like I have lost everything.”

“I could never remember Michael weighing more than 85 or 90 kilograms in his life before prison. But at the time of his death, he weighed 199 kilograms.”

“Michael deserved a better standard of healthcare. After being in prison, Michael was a version of himself that I could barely recognise. He was sad all the time, feeling depressed and unable to move. He was in a lot of pain.”

“I am grateful that this inquest has taken the time to properly understand Michael’s experience in prison and how much prison affected him. I’m glad this inquest has uncovered the issues in Michael’s medical care in prison that we would otherwise not have known about. I hope the Coroner’s recommendations are implemented, so something like this doesn’t happen again.”

“I want to thank the Coroner and Counsel Assisting for the care and attention they have given to Michael.”

“The Coroner has made good recommendations that we want the government to follow. The Coroner has done her job well – it’s now up to the government to make sure no more families lose their loved ones in prison. I want them to take these recommendations seriously and continue to follow them – not just forget about them in a few months or years.”

Quotes Attributable to Nerita Waight, CEO of the Victorian Aboriginal Legal Service:

“Coronial Inquests into Aboriginal deaths in custody are always incredibly difficult for families and loved ones, as well as the broader community. Our thoughts are with Maree, and Michael’s friends and family during this time. We hope these findings bring some peace, and that their fight for justice can finally see change in the prison healthcare system.”

“Equitable, holistic and culturally safe healthcare while in prison isn’t a huge ask, yet the voices of families continue to be ignored. ACCHOs must be resourced effectively to support our community while in prison, so they can return safely to their families. Aboriginal health should be in Aboriginal hands.”

“Just last week another national review into prison healthcare recommended that the government resource ACCHOs to develop self-determined models of care and provide primary health, social and emotional wellbeing services to Aboriginal people in prisons. This follows a scathing report by the Victorian Ombudsman of the state of healthcare in Victoria’s prisons in March this year, that the government has yet to respond to.”

“This coronial inquest has yet again exposed the inequity in prison healthcare and the devastating outcomes for our community. Victoria is undertaking a truth telling process, and we have entered treaty negotiations with the state. But if the state will not listen and act on these recommendations, and the many recommendations that have come before it, what faith are we to have in government?”

Quotes Attributable to Siobhan Doyle, Head of the Civil Law and Human Rights Practice at the Victorian Aboriginal Legal Service:

“Working with Maree during this inquest was an honour. She has never wavered from her resolve to use this process to help ensure other families don’t have to go through what she did. I hope the recommendations of the Coroner are implemented in full.”