Coroner's Finding: Morrison, Wayne Fella

Contributing factors

• Marked physical exertion during violent resistance to restraint
• Acute psychological and emotional stress
• Pre-existing coronary artery disease with focal moderate-to-severe atheroma of right coronary artery
• Potential respiratory compromise from spit mask use
• Delay in commencement of CPR (approximately 3 minutes after collapse)
• Placement in prone position during restraint and transport
• Inadequate training of correctional officers in restraint equipment and CPR
• Failure to communicate mental health concerns from Holden Hill to Yatala staff
• Inadequate risk assessment processes at admission

Coroner's recommendations

1. Appointment of an independent Board of Inquiry to review key findings with emphasis on restraint training content and delivery, supervisory training, performance review processes, enforcement of refresher training in restraint/first aid/CPR, risk management processes, and record-keeping requirements
2. Prohibition of operational duties involving prisoner contact unless correctional officers have completed DCS Control Restraint Defensive Training, current refresher training, current First Aid certificate, and annual CPR renewal
3. Recording of training expiry dates on correctional officers' identity tags in tamper-proof form
4. Placement of resuscitation equipment and automatic external defibrillators in all areas managing prisoner arrivals (e.g., sally ports)
5. Repeal of legislative provisions enabling Holden Hill police cells and similar facilities to be declared as prisons
6. Implementation of Recommendations 2-10 from Deputy Coroner White's findings in the Joshua Marek Stachor inquest
7. All first-time Aboriginal prisoners must be placed in shared cells with SA Prison Health Service notification if relocation to single cell occurs
8. Provision of information pamphlets about Aboriginal health and liaison services to all Aboriginal prisoners
9. SAPOL officers at Holden Hill attend Yatala for biometric database entry to facilitate incident response
10. DCS develop a Memorandum of Understanding with the Public Service Association and Correctional Officers Legal Fund regarding prompt access to legal advice after incidents