The NSW Deputy State Coroner today delivered his findings in the Mark Stephen Holcroft Inquest (see attached), saying disciplinary action should be considered against one of the guards who observed Mr Holcroft’s death.

Mr Holcroft was a low security inmate who died of a heart attack while travelling in a NSW prison van between Bathurst and Tumbarumba on 27 August 2009.

The Public Interest Advocacy Centre (PIAC) represented three members of Mr Holcroft’s family at the Inquest.

Mr Holcroft had experienced chest pains a week before he went on his fatal journey and received two ECG tests. However, a doctor employed by Justice Health, Dr Suresh Badami, acknowledged that he made an error interpreting the results of these tests.

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

The Coroner also heard evidence from a former prisoner, Andrew Bond, who was inside the van when Mr Holcroft died. Mr Bond said there was no way to alert the guards to what was happenning, so they yelled and waved at security cameras.

The Coroner recommended that prisoners receive adequate food and water during transfers, and a toilet stop if the journey is over three hours.

The Coroner also recommended that all transport vehicles be equipped with two-way communication systems at the earliest possible date.

He said disciplinary action should be considered against a guard, Peter Augustine Sheppard, ‘with particular regard to his actions as an observer’ at the time Mr Holcroft died.

PIAC chief executive officer, Edward Santow, urged the Minister for Justice, Greg Smith, to take the lead on implementing these recommendations.

‘Mark Holcroft’s death focuses attention on the terrible conditions prisoners often endure when they are transported in NSW.

‘The Coroner’s recommendations acknowledge prisoners’ basic rights,’ Mr Santow said.  

Contact: Dominic O’Grady. Ph: (02) 8898 6532 or 0400 110 169.

Photo: PIAC Solicitor Peter Dodd (left) outside the Coroner’s Court, with Nerida and Christopher Holcroft.

Related coverage:

Officer faces disciplinary action over death in prison van, SMH

As prisoners screamed for help, a man lay dying, SMH 

Cries for help ignored, ABC Lateline