AUSTRALIA
Roger Davies died with nine broken ribs. Police deemed his death non-suspicious and sent him to a pauper’s grave


Christopher Knaus

 Chief investigations correspondent

GUARDIAN AUSTRALIA
Sun, 4 February 2024 

Family photos of Roger Davies, a homeless man whose body was found, showing signs of violence, in an abandoned house three years after he died

Composite: Supplied

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In the shell of an abandoned house, beneath cobwebs spun across blackened walls, the skeleton of Roger Davies lay forgotten amid the rubbish.

Davies had come to this burnt-out home in Granville, western Sydney, seeking shelter, a place to squat alongside other rough sleepers fleeing Australia’s broken housing system.

Instead the 42-year-old army veteran found a shocking and premature end, an experience common to Australians experiencing homelessness.

Davies’ body then lay on the ground floor of that abandoned house for three long years, 140 metres down the road from the local police station.

Passersby noticed an overpowering smell but did nothing and Davies was discovered only by chance in April 2015 when a woman arrived to scavenge through the refuse.

She found Davies, still dressed in the blue shirt and brown pants he died in, a watch hanging loosely from his skeletal wrist.

Upstairs, police would later find an unanswered plea for help: an application for emergency housing filled out in Davies’ name about one month before he is believed to have died.

In shaky handwriting, Davies told the department he’d been seeking public housing for years and was now becoming desperate.

“Getting robbed all the time,” he wrote, indicating he was facing “violence and/or harassment from another person” in the squat house.

The deaths of Australians experiencing homelessness are largely invisible. No government in the country attempts to count or understand what is driving them, putting us at odds with other western nations.

In an attempt to shine a light on this crisis, Guardian Australia has spent 12 months identifying and investigating 627 homelessness deaths.

The investigation involved analysis of more than a decade of non-public death reports to state and territory coroners, a review of inquest findings since 2010, and dozens of interviews with rough sleepers, victims’ families, researchers and advocates.

The Guardian has found that, on average, people experiencing homelessness are dying at an average age of 44. That is vastly premature and a life expectancy gap of more than three decades.

It is the first time the life expectancy gap has been measured at a national level and, despite the data’s limitations, the finding is broadly in line with studies in Perth and Sydney.

The investigation also found suicide and overdose, known as deaths of despair, are primary drivers of death. Researchers say such deaths are inextricably linked to the despair and hopelessness of homelessness.

The investigation identified a wide range of systemic failings contributing to deaths, including gaps in health and mental healthcare, the critical undersupply of public housing and failures of the justice system.

A postmortem examination would find Davies sustained fractures to nine ribs about the time of his death.

Despite the signs of potential violence and Davies’ handwritten complaints, police records show officers formed the opinion there was “no evidence of suspicious circumstances”.

“There is an absence of any severe physical injury, large amounts of blood loss, known conflicts or possible motive for any person to seriously harm the deceased,” the investigators wrote.

Instead, police formed the opinion Davies had overdosed, despite no record drug paraphernalia being found at the scene and no toxicology report or other supporting evidence.

The investigators said they had based their opinion on his “history”.

Davies’ family were told nothing of his death for more than two years, neither by police nor the state government.

Police knew Davies was from Adelaide and had the names and dates of birth of his brother and sister, but documents suggest they first called their counterparts in South Australia seeking a family contact number on 20 November 2017, two and a half years after the body was found.

“He had been put in a pauper’s grave by the time we found out … before we even found out that he was deceased,” said Davies’ sister, who asked not to be named.

“There was no closure, there’s never going to be any closure, and up until now with you, there’s no one who’s cared.”
An invisible crisis

Nobody really knows how many rough sleepers are dying in Australia. It’s a hidden crisis – there is simply no national data.

Guardian Australia has spent 12 months identifying and investigating 627 homelessness deaths like Davies’ using 10 years’ worth of non-public death reports to state coroners, an analysis of inquest findings since 2010 and interviews with dozens of homeless Australians, victims’ families, frontline support workers and researchers.

The findings are stark.

They show Australians experiencing homelessness are dying prematurely by a margin of more than three decades. The average age of death is 44.

Suicides and overdoses are major drivers. They accounted for one-fifth and one-third of the 627 deaths, respectively.

Researchers and homelessness groups describe such cases as “deaths of despair” and say they are inextricably linked to the trauma and loss of hope associated with homelessness.

Indigenous Australians were also vastly overrepresented among the 627 deaths. About 20% involved an Aboriginal or Torres Strait Islander person.

Other rough sleepers are victims of extreme violence.

They have been found dead in parks and squats, and on the street shot, stabbed or bashed to death, including one man who was found in the Domain, in the centre of Sydney, with slash wounds to his neck, and a Tasmanian man who was bashed horrifically and set on fire while sleeping rough, an attack later connected to his sudden epilepsy death.Interactive

In many cases, people experiencing homelessness died in ways that were either preventable or directly linked to systemic failures across the housing, health and justice sectors.

In two cases identified by the Guardian, rough sleepers presented to hospital as suicidal, associating their suicidal ideation with their lack of housing.

Medical notes in one of the cases show a man known by the pseudonym of Channa, a 26-year-old from the northern rivers in New South Wales, told hospital staff: “It is hard to find a reason to live when you have nowhere to live.”

No emergency housing was available and Channa was discharged. He was found dead a short time later in a suspected suicide.

In four other cases, rough sleepers died after police enforcement of minor public order offences, such as drinking in public or public nuisance, a practice experts have long urged against. The arrests either led to the use of force or to deaths in custody.

These are people, like you and me, and they deserve to be treated equally and with compassion

Nick Ware, lawyer

In Western Australia, Guardian Australia has spoken to two Indigenous families who say their loved ones died by suicide after being evicted from public housing.

Davies’ case and many of the 627 deaths investigated by the Guardian are policy failure writ large, the horrific reality of Australia’s inaction on housing its most vulnerable and providing them with wraparound support.

Documents show both federal and state governments have failed to take even the most basic step to investigate the crisis.

In 2021 governments across the country rebuffed or ignored requests from the homelessness sector to establish an annual count of homelessness deaths, a measure adopted by other western nations to inform policy responses and drive accountability.

For Davies’ family, this lack of interest is not new.

Davies’ sister remembers her brother as kind and protective, someone who lost his way after family trauma and discharge from the military.

She says police showed little interest in investigating his death, despite clear evidence of perimortem rib fractures and his handwritten complaints of robberies and violence.

Police documents show they declined to send items found at the scene to forensics and only interviewed two rough sleepers who had a past association with Davies before arriving at the conclusion that he overdosed.

“They wanted it to just go away,” Davies’ sister said. “I got told at the start that pretty much there was no foul play. And then it would seem that that’s not the case.

“It didn’t really seem like it mattered much … And that’s not just the police, that’s also with the media.

“No one really gave a shit.”
‘It was a dark, dark place’

When Beatrice Christian became homeless in Perth in 2018, she sought safety in numbers. She and eight other rough sleepers stuck together, watching each other’s backs.

Christian, a Koori woman, still refers to them as “my little gang”.

Five years later only three of them are still alive. “One, I went to her funeral only two weeks ago,” she says. “She was the baby of the gang.

“Another old gentleman passed of pneumonia about a month ago, I think. There’s only three of us left and their health isn’t the best either, they’ve got the stigma around them as well. They get treated as drunks.”

Studies in Australia and abroad have shown that even a single period of homelessness is profoundly harmful to a person’s physical and mental health.

“It almost drove me to suicide a few times,” Christian says. “It was a dark, dark place.”

The level of unmet demand for support is vast. Every day in 2022-23 there were nearly 295 unmet requests for help to specialist homelessness services.

Christian says she struggled to get proper healthcare. Doctors stigmatised and disbelieved her due to her homelessness, she says, and a note made on her file years ago saying she was suffering drug-induced psychosis.

But Christian is a survivor.

At 54, she has lived longer than most Australians experiencing homelessness, something she attributes to her securing housing in 2020 with the help of the Perth-based advocacy group Daydawn.

“My health would have deteriorated a lot quicker out there than it is now,” she said. “It’s slowly progressing but I would have deteriorated – I would have been gone a long time ago.”

Davies also complained of his failing health while sleeping rough.

Both his and Christian’s cases expose gaps in the health system, a problem experts say is compounded by the lack of funding for specialist homelessness healthcare services.

Davies’ handwritten housing application, seen by Guardian Australia, suggests he suffered an infection while recovering from gall bladder surgery “under a bridge”.

He also complained of struggling to walk on his prosthetic leg and of his difficulties in keeping the area clean while sleeping rough.

“I need a new prosthesis due to 2 bad blisters on either side of my knee causing me great pain to walk,” he wrote. “Having to buy new prosthetic socks every fortnight because I haven’t been able to wash them.”
‘Uncomfortable truths’

No government in Australia bothers to collect data about the life expectancy gap between people experiencing homelessness and the general population.

In an attempt to address this failing, Guardian Australia engaged researchers at the National Coronial Information System, who have access to non-public death reports made to coroners, to examine known homelessness deaths between 2010 and 2021.

In the 627 deaths they could find – nowhere near a full count of homelessness deaths – they found an average age of death of 45.2 years for men and 40.1 years for women.

That represents a life expectancy gap of more than three decades between the median age at death for the general population, which is 79 years for men and 85 years for women.

Despite the limitations of the data, it is the first time the life expectancy gap has been shown at a national level.

The finding is in line with a much more comprehensive but localised study in Perth, which found the median age at death was 50, and a study limited to three homelessness services in inner-city Sydney, which also found a median age of death of 50.

It also accords with government data in England and Wales, where the average age of deaths for people experiencing homelessness is 45 for men and 43 for women, and in Scotland, where deaths are most common among women aged 35 to 44 and men aged 45 to 54.

In 2021 the lack of Australian data prompted David Pearson, the chief executive of the Australian Alliance to End Homelessness, to pen a letter to the then health minister, Greg Hunt.

He warned that homelessness deaths and Australia’s failure to collect even the most basic data about them was a “national emergency that requires urgent national leadership”.

Pearson urged the Morrison government to commission the Australian Institute of Health and Welfare to develop a reporting framework that would allow hospitals, coroners and health and homelessness services to report on the deaths of rough sleepers they come in contact with.

He said Hunt had not responded and that the Morrison government, despite having a minister for homelessness, had referred him to state governments.

“The commonwealth said it was a state issue,” he said. “Most of [the states] didn’t respond. Some of them said, ‘Let’s have some further conversations’, and then nothing happened.”

The Perth study, led by University of Notre Dame Australia’s Prof Lisa Wood, has shown it is possible to count homelessness deaths.

Her Home2Health research team, operating with threadbare funding, compares hospital and other death records with a pool of more than 8,500 people known to have experienced homelessness in the city, built from client lists of local homelessness services.

By cross-checking the known group against hospital records and the WA register of births, deaths and marriages, they identified 360 deaths between 2020 and 2022, with a median age at death of 50 years.

“I can’t help but think that it’s such an uncomfortable truth that in some ways it’s less confronting for governments and others if it remains hidden,” Wood says.
Preventable tragedies

The stories of Australia’s homeless dead reveal failure after systemic failure.

In the case of Terrence Malone, the missed opportunities to divert him from a premature death are almost too many to count.

Malone, an Indigenous man loved deeply by his children, spent much of his life helping others.

He worked as a firefighter and spent 16 years as a psychiatric nurse in Toowoomba, a career that ended after assaults and threats on his life triggered bipolar and post-traumatic stress disorders and alcohol dependency.

Malone moved to Brisbane but was left on the streets after police impounded his van and shelters kicked him out due to their zero-tolerance alcohol policies.

It is really dangerous to be experiencing homelessness

Deborah Di Natale, Council to Homeless Persons

In mid-2014 he was accepted by an alcohol rehabilitation service in Toowoomba but was told he could not start until he was off painkillers prescribed for a shoulder injury. The injury required surgery that the local hospital repeatedly delayed and refused to prioritise to get Malone into rehab.

Just months later Malone was imprisoned for the first time in his life on minor property offences and later had his parole revoked over a missed appointment.

Parole officers, having made an underwhelming attempt to find him, deemed his whereabouts unknown, a regular problem for rough sleepers entangled in the justice system, and ordered that he be found and locked back up.

Before he went back behind bars Malone told police – who had no real difficulty finding him – that he was suicidal and had made prior attempts on his life.

A Brisbane correctional centre failed to flag him as a suicide risk. Prison officers gave him razor blades and left him alone in a cell without regular observations.

Malone was found dead the day after his admission. He was 54.

Nick Ware, a lawyer and former police officer, represented Malone’s family at the subsequent inquest, which found that the death could have been prevented.

Ware says Malone’s death left an indelible mark on him: “It’s easy to lose sight of the fact that these are people, like you and me, and they deserve to be treated equally and with compassion.”

Similar tragedies are repeated all over the country.

The Council to Homeless Persons chief executive, Deborah Di Natale, describes premature death as a “stark reality” of homelessness.

“It is really dangerous to be experiencing homelessness,” Di Natale said. “We also know that people without homes are at increased risk of death due to untreated illnesses – respiratory illnesses, mental health-related deaths and addiction-related deaths.”

Despite this, rough sleepers’ deaths rarely make their way into public discourse.

Di Natale says silence is fuelled by stigma and false assumptions. “We shouldn’t lose sight of the fact that these people are loved by their families, their communities and their [support] workers,” she says.

The housing application found next to Davies’ body shows he was in a desperate state. His handwritten words show a man of failing physical and mental health, all linked to housing.

“I’m thinking of suicide, I’ve been trying to get housing since all my stuff at a bedsitter was thrown in the charity [bin],” he wrote.

New South Wales police did not answer specific questions about the case – a spokesperson said it was a historical matter and they would not be able to review the material in time for publication.

They referred Guardian Australia to the coronial findings. The coronial inquest was not critical of the police investigation.

A Department of Communities and Justice spokesperson said destitute funerals were facilitated by NSW Health but that NSW Police were responsible “for undertaking all necessary investigations before providing advice to the coroner that senior next of kin enquiries have been exhausted and that a deceased is destitute”.

Investigators told the coroner they attempted to contact Davies’ relatives in 2015, but that phone numbers on NSW police systems were “not current”. They also said the number they eventually obtained for Davies’ brother in November 2017 from South Australian police only would have been available from June 2017 onwards.

Davies’ sister is clear-eyed about what she wants to come from her brother’s death.

She says more housing must be given to those who need it most, with wraparound support services to address their mental and physical health.

It is what housing and homelessness groups have been calling for for years, an international best-practice model known as “housing first”.

“The housing system needs to become more available for people who need it and less available for people who are just taking advantage of [it],” Davies’ sister says. “I realise that some people have drug issues and stuff that makes it hard, or make people’s priorities a bit of a mess …

“I think that they’re the ones who perhaps need the help the most. If they had somewhere to stay every night and somewhere to get off the drugs that was safe, perhaps they would. But if they’re out there, then they’re not going to want to.

“It starts from the ground up.”

• In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org