Coroner investigates death in prison van

On 12 August 2011, the NSW
Deputy State Coroner, Paul McMahon, delivered his findings in the Inquest into Mark
Holcroft’s death. PIAC represented Mr Holcroft’s two sisters and one brother at
the Inquest.

Mr Holcroft suffered a heart
attack in a prison van while travelling from Bathurst to Mannus Correctional
Centre in NSW. Although other prisoners in the van banged on the side of the
van and tried to get the attention of the guards, the van did not stop until it
reached Mannus. Sadly, Mr Holcroft had died by then.

The Inquest highlighted
several issues:

  • There was no
    two-way communication in the van; 
  • There was only
    one observation camera working in each of the van’s compartments; 
  • There was no duress
    button that prisoners could use to alert guards in the front section of the
  • Prisoners were
    not given food, water or toilet stops on a journey that lasted more than four

Mr Holcroft reported to
Justice Health nurses that he had chest pains a week before he went on his
fatal journey. He was given ECG tests, but a doctor employed by Justice Health acknowledged at the Inquest
that he made an error interpreting the results of these tests.

Expert evidence given at the
Inquest said Mr Holcroft’s death was preventable because if the ECG tests were
properly interpreted, he should have been immediately hospitalised and treated.

The Coroner found that Mr Holcroft’s
death was primarily the result of the failure of Justice Health to provide him
with proper care.

It is troubling that the
original police investigation for the Coroner did not identify the standard of
the health care received by Mr Holcroft as an issue for the Coroner.

It was only when PIAC raised
the issue that the Coroner requested an expert report. This highlights the need
for the involvement of investigators with an expertise in health care in
coronial investigations. It also highlights the need for involvement of bodies such
as the Health Care Complaints Commission in the investigation of healthcare-related
deaths before an inquest takes place.

The Coroner made eight
recommendations to the Commissioner of Corrective Services. The most
significant is that the Standard Operating Procedures and Departmental
practices for inmate transfers should be reviewed so as to ensure that:

  • Adequate
    drinking water is always available to inmates during transfers,
  • If
    the proposed journey is anticipated to be longer than three hours a toilet stop
    should be included during the course of the journey, and
  • If
    the proposed journey is anticipated to be longer than four hours a meal should be
    provided to each inmate prior to the commencement of the journey as well as
    during the course of the journey.

The Coroner recommended a
review of two-way communication systems that have been installed in prison vans
following Mr Holcroft’s death to ensure such systems are available in all prison
vans at the earliest possible date.

The Coroner also recommended that
disciplinary action be considered against a Corrective Services Officer, Peter Augustine
Sheppard, with particular regard to his actions as an observer at the time Mr
Holcroft died. The Coroner found that had Mr Sheppard undertaken his duties in
a proper fashion he would have been aware of the welfare concern regarding Mr

The finding in regard to Mr
Sheppard raises significant questions about the attitudes within Corrective
Services NSW towards the human rights of prisoners.

At no stage during the
Inquest did Corrections NSW concede that what happened in the van on 27 August
2009 was in any way inappropriate or of concern. Justice Health apologised to
the Holcroft family at the inquest and acknowledged its failure to provide Mr Holcroft
with proper care and the consequences of that failure. However, when given an
opportunity, Corrective Services NSW failed to do the same.

PIAC believes the culture of
Corrective Services NSW should respect the human rights of prisoners and their
basic human needs. This should be evident in policies and protocols that
reflect international and national standards for the care of prisoners.

PIAC has called on the NSW
Justice Minister, Greg Smith, to take the lead in the implementation of the
Coroner’s findings.

The Conference of State and
Federal Corrections Ministers has agreed in principle to finalise national
standards for prison transport. PIAC will urges the Ministers to examine closely
the facts of Mr Holcroft’s death, and to take full account of the Coroner’s
findings and recommendations, when finalising these standards.

Photo: PIAC Solicitor Peter Dodd and Christopher Holcroft, outside the Coroner’s Court.

Related coverage: Coroner says prisoners deserve better

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