Smith, David Edward
Deceased
David Edward Smith
Demographics
21y, male
Date of death
1994-09-28
Finding date
2006-03-17
Cause of death
Multiple stab wounds inflicted by Andrew Kranz who was assisted in the murder by other prisoners
AI-generated summary
David Edward Smith, 21, was murdered in prison by inmates with 31 stab wounds after being forcibly moved to a high-risk unit despite clear and repeated warnings of danger. Staff ignored his requests for protection and failed to follow established policy. The coroner found the death was both predictable and preventable, caused by individual failures to perform duties, communication breakdowns, and failure to implement protection procedures. Key lessons: staff must act immediately on prisoner protection requests regardless of administrative obstacles; risk assessments must be completed before such transfers; chain of command must ensure all relevant information reaches decision-makers; protection policies and forms must be readily available; and training on protection procedures must be universal.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure to assess risk prior to prisoner transfer
- Failure to follow established protection procedures
- Failure to properly communicate prisoner's concerns up chain of command
- Protection policy not effectively implemented at the centre
- Staff unfamiliar with new protection forms and policy introduced 4 months prior
- Administrative incompetence in information relay
- Acting General Manager not informed of prisoner's verbal statements that he would be killed
- Withdrawal of protection application documented only by verbal account with no written confirmation
- Prisoner forcibly moved to unit despite clear objections
- Inadequate risk assessment by Sentence Management Coordinator
- Reduced supervision of unit at time of attack (one officer covering two units during meal break)
Coroner's recommendations
- Review of protective custody procedures to ensure centres are familiar with the policy
- Assessment of staff ability to perform protective custody management functions
- Staff training on risk management associated with prisoner protection
- Establishment of succession training program for all staff from Senior Correctional Officer upward, state-wide
- Implementation of random audits to ensure compliance with searching procedures and rules
- Clarification and update of General Manager's Rules to accurately reflect QCSC policy on protection
- Consideration of disciplinary action if justified
- Advice from Director of Public Prosecutions regarding potential charges against other prisoners identified as involved
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —