The South Australian deputy coroner has found there were a “litany of failings” that led to the death of the Indigenous man Wayne Fella Morrison in custody but declined to make any findings against the corrections officers involved.
Morrison, a 29-year-old Wiradjuri, Kokatha and Wirangu man, died at Royal Adelaide hospital on 26 September 2016 after being restrained at the wrists and ankles, placed in a spit-hood and positioned face down in the back of a van as he was transported to Yatala labour prison.
Morrison, who spent less than two minutes in the van, could not be revived and died in hospital three days later. He had not been convicted of any crime and was being held on remand at the time of his death. No CCTV video exists capturing what took place inside the prison transport van.
Coroner Jayne Basheer made a brief appearance at the coroner’s court in Adelaide on Friday when she declined to read her findings into the death in custody in full.
In her published findings, Basheer said the inquest had “revealed a litany of failings and shortcomings at every stage of Mr Morrison’s management whilst he was in the care and custody of the Department for Correctional Services”.
However, the coroner declined to make any adverse findings against the corrections officers involved and attributed to the death to a lack of training.
“The conduct of individuals must be considered against the whole of the evidence which includes glaring deficiencies in the training of correctional officers at Yatala Labour Prison which were exposed when these officers were called upon to manage a major incident,” Basheer said.
The coroner also found that the level of force used during the initial restraint was “reasonable and necessary”, however, the decision to carry Morrison by his arms and legs, face down, “once restrained” was not necessary and considered “an excessive use of force”.
The Department for Correctional Services CEO, David Brown, said his department was “giving careful consideration to the details of the report” but would not say whether any disciplinary action against his officers would be undertaken.
“I think the report was balanced and objective in terms of the actions and conduct of my staff,” he said.
Brown could not say how many officers involved with the incident remained with the department, saying a “significant number” involved were still employed though “some staff have left the agency”.
He said he “welcomed any review into the progress that we’ve made so far in implementing recommendations”.
The coroner recommended an independent agency be created to oversee the department’s adoption of recommendations owing to “the sheer number and nature of demonstrated failings and shortcomings” suggesting that it “is inappropriate for DCS to be left to remedy its own failings”.
She also said conditions at Holden Hill station, where Morrison was held before he was moved to Yatala labour prison, were “barbaric and inhumane”, akin to “solitary confinement”.
“It is shocking in the 21st century any person, including prisoners, would be housed overnight in such appalling conditions,” she said.
If proper procedure had been followed, including correctly identifying him as an Aboriginal man and a vulnerable person, it “may have prevented Morrison’s death”, the coroner said.
Basheer found “no single factor or mechanism” was responsible for Morrison’s death, instead finding the “potential causes are multifactorial in nature and include the effects of marked physical exertion, emotional and psychological stress and underlying coronary artery disease”.
In making the finding, the coroner relied on evidence from Dr Cheryl Charlwood who speculated the “controversial syndrome” known as “excited delirium” may have contributed to his death.
Charlwood had also given evidence she was “not qualified to provide an opinion on whether Mr Morrison was suffering from an acute psychotic episode at the relevant time”. The court did not seek external expert psychological evidence during the inquest.
“Excited delirium” was controversially cited by police in the US as a complicating factor in the death of George Floyd but its role was ultimately rejected. The term has also been relied upon by law enforcement and corrections officers in Australia mostly during deaths in custody matters.
The coroner said a provision of South Australian law that allowed corrections officers to claim “penalty privilege” against self-incrimination hindered the court’s ability to conduct an investigation about what occurred when Morrison was transported in a prison van.
Penalty privilege was claimed at least 71 times by the five officers who were present in the back of a prison transport van while Morrison was being moved to the prison’s high-security G division.
These protections have since been removed from the Coroners Act in South Australia by the previous government, but the changes do not apply retroactively.
Basheer cited this technicality as preventing her from compelling evidence from the prison guards, saying “one can understand the dismay of the Morrison family when they learned of the anomaly that existed in South Australia”.
The coroner said “there are so many other unanswered questions” related to the “van journey” but rejected submissions from counsel assisting and lawyers for Morrison’s family calling for recommendations that the government create a special investigative body with the power to compel evidence to re-examine what occurred.
Basheer also said there was no evidence to support suggestions key documents had been deliberately removed, or that Morrison had been managed in a way that would punish him during restraint.
Morrison’s family were not present for the findings to be delivered and have asked for privacy.
