Coroner's Finding: CARTER Marshall Freeland

Contributing factors

• intravenous heroin use with low tolerance
• failure to call medical emergency code
• 7-minute delay in accessing cell (exceeded 3-minute threshold for brain damage prevention)
• inadequate transfer of medical and drug history information between juvenile and adult detention facilities
• failure to strip-search cellmate before isolation
• failure to conduct urine testing of cellmate
• weak initial police investigation
• cellmate housing despite medical contraindications
• clandestine heroin supply in prison

Coroner's recommendations

1. The Chief Executive Officer of the Department for Correctional Services consider methods of discouraging or preventing exchange of contraband by means of 'lines' between cells
2. The Department for Correctional Services should install a system whereby a cell at Yatala Labour Prison may be opened electronically in the event of an emergency
3. Standard Operating Procedure 6 in relation to strip-searching after 'incidents of death' be amended to ensure that in all incidents of death, a strip search of all prisoners who had contact with the deceased immediately prior to the incident be conducted as soon as practicable, and their clothing is bagged and labelled and provided to police if required. If a strip search cannot be conducted shortly after the incident, the prisoner or prisoners should be separated from others and observed to ensure that they do not dispose of evidence