Coronial Inquests

Mark Holcroft

In 2011, PIAC represented the family of Mark Holcroft, who suffered a heart attack in a prison van while he was travelling between correctional centres in NSW. Although other prisoners banged on the side of the van and tried to get the attention of the guards, the van did not stop until it reached its destination. Sadly, by this time Mr Holcroft had died.

The inquest highlighted several issues:

  • there was no two-way communication in the van;
  • there was only one observation camera working in each of the van’s compartments;
  • there was no duress button that prisoners could use to alert guards in the front section of the van; and
  • prisoners were not given food, water or toilet stops on a journey that lasted more than four hours.

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

The Coroner made a number of recommendations to the Commissioner of Corrective Services. The most significant of these was that inmates should be given adequate drinking water during transfers, and adequate toilet breaks and meals during long journeys. The Coroner also recommended that two-way communication systems be installed in all prison vans.

Corrective Services NSW responded to the Coroner’s recommendations, issuing a ‘Commissioner’s Instruction’ to ensure that inmates receive adequate food and water on long journeys, as well as toilet and exercise breaks at secure locations. At least 39 transport vehicles were fitted with two-way intercom systems.

Trent Lantry

In 2008, PIAC and Veronica Appleton successfully claimed damages in the District Court of NSW after the death of Ms Appleton’s son, Trent Lantry, in the Cessnock Correctional Centre.

Mrs Appleton’s son was a young Aboriginal man. He committed suicide when he was placed in a cell on his own after being released from an acute crisis management unit. Mr Lantry’s cell had obvious hanging points and milk crates supported his bed.

Judge Quirk stated:

‘By placing Trent in a cell with movable milk crates supporting his bed, the defendant provided him with the opportunity to kill himself. I also find that not monitoring him or assessing him in some fashion and placing him in a cell alone amounted to breaches of its duty.’ 

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