Inquest into the Death of Ward
Deceased
Ian Ward
Demographics
46y, male
Date of death
2008-01-27
Finding date
2009-06-12
Cause of death
Heatstroke
AI-generated summary
Ian Ward, a 46-year-old Aboriginal man, died from heatstroke on 27 January 2008 while in custody, transported by GSL Custodial Services in a Mazda E2500 prisoner van from Laverton to Kalgoorlie. The rear pod in which he was held was a metal enclosure with non-functioning air-conditioning in extreme heat (outside temperature over 40°C). The coroner found the van was unsuitable for long-distance prisoner transport, with numerous defects including a failed air-conditioning system, inadequate CCTV, non-functional duress alarm, and no temperature monitoring. GSL officers failed to check the air-conditioning before departure or conduct welfare checks despite the obvious risks. The death was entirely preventable and contributed to by multiple failures: the Department of Corrective Services' ownership of an unsafe vehicle fleet, GSL's inadequate policies and training, and the GSL officers' breach of duty of care. The coroner made 14 recommendations addressing vehicle replacement, staff training, monitoring procedures, bail processes, and the Inspector of Custodial Services' enforcement powers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Non-functioning air-conditioning system in rear prisoner pod
- Vehicle design unsuitable for long-distance transport in extreme heat
- Failure to check air-conditioning prior to journey
- Failure to conduct welfare checks during 3 hour 45 minute journey
- Inadequate CCTV monitoring system
- Non-functional duress alarm
- Lack of temperature monitoring equipment in pod
- Inflexible GSL policy placing remand prisoner in rear pod rather than forward pod
- Inadequate training and procedures for GSL staff
- Department of Corrective Services failure to replace aging vehicle fleet despite known problems
- Unlawful bail remand requiring custodial transport
- Insufficient water provision (only 600ml)
- No toilet facilities in pod
- Vehicle's deteriorating condition over 8 years of use
Coroner's recommendations
- Establish a statutory system enabling the Inspector of Custodial Services to issue Show Cause Notices to the Department of Corrective Services regarding human rights and safety issues in custody
- Insert terms of sections 34 and 39 of the Terrorism (Preventative Detention) Act 2006 into relevant legislation to extend protections to all persons in custody
- WA Police review training procedures to ensure officers understand the Bail Act 1982
- Department of the Attorney General not delegate Deputy Registrar powers to police officers unless satisfied they understand their duties and responsibilities
- Department of the Attorney General review use of Justices of the Peace in remote locations to ensure adequate training and assessment
- Department of the Attorney General monitor JPs performing court duties to ensure appropriate performance
- Department of the Attorney General review procedures to extend video conferencing availability for magistrate decisions, particularly those affecting liberty
- Department of the Attorney General review court procedures to limit unnecessary long-distance transportation of accused persons
- Department of Corrective Services replace the current prisoner transportation fleet with safe and humane vehicles
- Department of Corrective Services establish a replacement strategy and budget for regular vehicle replacement
- Department of Corrective Services conduct ongoing review of G4S policies and procedures relating to detainee welfare and duty of care
- Department of Corrective Services ensure sufficient contract monitors to regularly review operations in regional locations
- G4S provide all staff with appropriately detailed practical training in duty of care obligations with regular refresher training
- G4S provide training specific to supervisors' roles in regional locations regarding management skills and monitoring compliance with policies
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