- Published:
- Friday 10 April 2026 at 4:30 pm
Aboriginal and Torres Strait Islander people should be aware that this webpage contains the image of a deceased person.
The Coroner’s Court of Victoria has concluded an inquest into the passing of Jeffrey Winmar who died after being arrested by Victoria Police in November 2023.
Jeffrey, a proud Noongar man, was only 28 years old.
The eight-day inquest heard that Jeffrey had been hospitalised with serious injuries after he’d fallen unconscious following a police pursuit and never recovered.
The inquest examined the planning and execution of the arrest of Jeffrey, and the decision by police to request, cancel and re-request an ambulance during the arrest. It also looked at the cause of Jeffrey’s cardiac arrest, liver lacerations and clarification of his cause of death in general.
The findings of the inquest are expected to be delivered at a later date.
Jeffrey is among 628 Aboriginal people who have died in custody since the 1991 Royal Commission into Aboriginal Deaths in Custody.
This coming Wednesday (15 April) will mark 35 years since the signing of the Commission’s final report, which made 339 recommendations to improve the lives and outcomes for First Peoples. These included recommendations related to the coronial and justice system, health, housing, land rights and self-determination.
‘Thirty-five years on and many of the Royal Commission’s recommendations still have not been meaningfully implemented,' said Ashley Morris, Executive Director of First Nations Services at Victoria Legal Aid, which represented Jeffrey’s mother Ursulla for the inquest.
'It is deeply painful and traumatic for First Peoples to continually see our people die in custody. Every death is a person with a family, friends and community.
‘Still today, First Peoples are 17 times more likely than non-Aboriginal people to end up in custody. The Yoorrook Justice Commission found that over-policing, systemic racism and bias and insufficient investment in community-driven alternatives remain persistent barriers to change.’
Thirty-three Aboriginal and Torres Strait Islander people died in custody between July 2024 and June 2025. This accounted for 29 percent of all deaths in custody – the largest number since 1979–80 and almost double the average over the past 35 years.
Ursulla said she was hopeful the inquest would help bring about justice and accountability.
‘I love my son so dearly and he has been taken from me. I miss him and I miss his phone calls. The drone and body warn camera footage are the last images I have of Jeffrey, so I watch these all the time. I’ve been robbed of a son, and I feel sad I couldn’t protect him,’ Ursulla said.
‘I want justice for my son and for people to be accountable.’
Toby Hemming, CEO of Victoria Legal Aid said, ‘Jeffrey’s passing is a tragedy, and we acknowledge the strength of his family in seeking answers through this inquest. The issues examined go to the core of accountability and fairness in the justice system.
'We hope the coroner’s findings will provide some measure of justice for Jeffrey’s family and help strengthen confidence that these systems work to protect all members of the community.’
More information
Read Ursulla’s full statement prior to the inquest.
Read the joint statement from the Victorian Aboriginal Legal Service (VALS). VALS represented Jeffrey’s father, Pep, during the inquest.
Updated