The South Australian Deputy Coroner has found there were a "litany of serious failings and shortcomings" in how a first-time Aboriginal inmate was managed in both the police cells and at the state's highest security prison.
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Jayne Basheer has handed down her findings into the death of 29-year-old Wayne Fella Morrison – almost five years after the inquest started in 2018.
She found his death was possibly preventable, and labelled conditions under which prisoners were held at the Holden Hill police cells as "barbaric and inhumane".
"The conditions are more akin to punishment or solitary confinement," she said in her findings.
"It is shocking in the 21st century any person, including prisoners, would be housed overnight in such appalling conditions.
"The use of such cells to accommodate prisoners overnight should be prohibited."
Mr Morrison died in the Royal Adelaide Hospital in September 2016, three days after he was pulled unresponsive from a Yatala Labour Prison van surrounded by guards.
The prisoner – whose mental health had been deteriorating — was restrained with handcuffs, ankle flexi-cuffs and a spit hood, and put face down in the rear of the van after becoming violent towards prison guards.
He suffered a heart attack while under physical and psychological stress.
"The evidence received during this inquest has revealed a litany of serious failings and shortcomings in relation to Mr Morrison's management whilst in the care and custody of the chief executive of the Department for Correctional Services," Ms Basheer found.
She said these shortcomings took place at "virtually every stage of Mr Morrison's incarceration" – which included stints in the DCS-managed Holden Hill cells, Elizabeth cells and Yatala.
Prisoners housed at Holden Hill were locked up for 24 hours a day without natural light, had no access to exercise, books or television, and were not permitted visits from family, Ms Basheer said.
She said the department failed to identify Mr Morrison as Aboriginal and was unable to provide any documents relating to his mandatory risk assessments.
"The missing documents have never been located," she said.
"The fact that such documents could not be produced at a coronial inquest into the death of a first-time Aboriginal prisoner should ring alarm bells."
Ms Basheer made a raft of recommendations, including the appointment of an independent inquiry board to undertake a comprehensive review of her findings around restraint and first-aid training.
"The sheer number and nature of demonstrated failings and shortcomings leads to the conclusion that is inappropriate for DCS to be left to remedy its own failings and independent oversight is required," she said.
She said at the time of Mr Morrison's death, correctional officers were "required" by the department to undertake refresher restraint training.
"But the evidence has established beyond doubt that the so-called requirement was not enforced," she said.
Inquest urges defensive training for guards
Ms Basheer recommended all prison guards be banned from operational duties until they complete the DCS Control Restraint Defensive Training program and have a first-aid certificate.
She also recommended that all first-time Aboriginal prisoners be placed in shared cells and if they do require a solo cell that the SA Prison Health Service is notified.
During the inquest, it was revealed the prison guards present in the van did not provide police with statements, and many refused to give evidence on the grounds of self-incrimination.
It prompted lawyers for the Morrison family to seek a recommendation that DCS lay disciplinary charges against the van guards, and five of them be referred to the Director of Public Prosecutions for criminal investigation.
But Ms Basheer said she could not make that finding under the Coroner's Act.
The Morrison family also wanted the deputy coroner to make a finding that DCS has failed to implement recommendations made after the Royal Commission into Aboriginal Deaths in Custody.
"The examination of the implementation of recommendations of the Royal Commission at Yatala Labour Prison was not central to this inquest and would necessarily require a whole of government approach," Ms Basheer said.
"It is not an appropriate matter on which to make recommendations."
In response to the findings, DCS chief executive David Brown said he would do "everything in my power" to ensure another prisoner did not die in similar circumstances to Mr Morrison.
"I can commit to giving careful and due consideration to the recommendations," he said.
He said he would respond to the recommendations, noting changes had already been made after three investigations completed by DCS, police and the State Ombudsman.
"Since these investigations were completed, the department has been focused on implementing a full suite of actions in response," he said.
Mr Brown said the use of spit hoods was banned in 2021, CCTV had been installed inside prison transfer vans and the cells at Holden Hill have been decommissioned.
He said staff training had been updated, and he would consider the recommendation that guards be banned from operational duties if they were not up-to-date with restraint and first-aid courses.
"Improvements have also been made to ensure Aboriginal prisoners are identified as early as possible in the admission and induction process, and they have access to Aboriginal liaison officers," he said.
Mr Brown also said he would welcome any independent review or oversight into his department's implementation of the coronial recommendations.
