Coronial inquests, coronial law reform

represents families in coronial inquests and has a continuing interest in coronial
law reform

Mark Holcroft

In 2011, PIAC represented the
family of Mark Stephen Holcroft, who suffered a heart attack in a prison van while he
was travelling between correctional centres in NSW. Although other prisoners
banged on the side of the van and tried to get the attention of the guards, the
van did not stop until it reached its destination. 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 hours.

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

The Coroner made a number of
recommendations to the Commissioner of Corrective Services. The most
significant of these was that inmates should be given adequate drinking water
during transfers, and adequate toilet breaks and meals during long journeys.
The Coroner also recommended that two-way communication systems be installed in
all prison vans.

Corrective Services NSW responded to the
Coroner’s recommendations
, issuing a ‘Commissioner’s
Instruction’ to ensure that inmates receive adequate food and water on long
journeys, as well as toilet and exercise breaks at secure locations. At least
39 transport vehicles were fitted with two-way intercom systems.

Pictured, above right, is PIAC solicitor Peter Dodd with members of Mark Holcroft’s family outside the Coroner’s Court.

Trent Lantry

In 2008, PIAC and Veronica Appleton successfully claimed damages in the District Court of
NSW after the death of Ms Appleton’s son, Trent Lantry, in the Cessnock
Correctional Centre. 

Mrs Appleton’s son was a
young Aboriginal man. He committed suicide when he was placed in a cell on his
own after being released from an acute crisis management unit. Mr Lantry’s cell
had obvious hanging points and milk crates supported his bed. 

Judge Quirk stated: 

‘By placing Trent in a cell
with movable milk crates supporting his bed, the defendant provided him with
the opportunity to kill himself. I also find that not monitoring him or
assessing him in some fashion and placing him in a cell alone amounted to
breaches of its duty.’

Scott Simpson

PIAC assisted the family of Scott Simpson, who committed suicide in June 2004 after spending
the final two years of his life in solitary confinement in Long
Bay prison.

At the time of his death, Mr
Simpson was suffering from a severe mental illness. However, because of his
security classification, he was not receiving any ongoing
therapeutic treatment.

Mr Simpson’s mother fought to
hold the Department of Corrective Services and Justice Health accountable for
her son’s death. In 2006, the NSW Deputy State Coroner found that
Justice Health and the Department of Corrective Services had failed to ensure
that Mr Simpson received adequate and timely medical treatment for his
mental illness. 

In handing down her findings,
the Coroner said: “More could have been done, should have been done and it
wasn’t”. The Coroner made recommendations about new standards that should be in
place for the treatment of mentally ill inmates in the NSW prison system. 

Law reform

PIAC’s submission to the
Senate Community Services Committee’s Inquiry
into suicide in Australia highlights ways to enhance the coroner’s
role in suicide prevention through law and policy reform. 

PIAC’s submission to
the Western Australian (WA) Law Reform Commission’s Review of Coronial
Practice in Western Australia

discusses five areas PIAC considers are essential reforms for
coronial law and practice Australia-wide.  

PIAC continues to pursue coronial
law reform, advocating a mandatory government response to recommendations by
the Coroner. 

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