Caroline Andersen left the South Australian Supreme Court last Thursday evening feeling hurt and deflated.
It has been five years since her son, Wayne Fella Morrison, died following an incident in his holding cell at Yatala Labour Prison, and three years since the Coronial inquest into the circumstances surrounding his death began public hearings.
Last week, the coroner heard from Darren Hosking, the boss of Yatala Labour Prison in September 2016 when Morrison – a 29-year-old Wiradjuri, Kokatha and Wirangu man – died after being restrained by twelve prison guards in his holding cell.
'He didn't say sorry'
Over the course of the day Hosking had been asked whether he was sorry for what happened to Morrison, but in giving his answer he baulked.
“I think there are certainly some learnings.” Hosking admitted.
Pushed further, Hosking was told that Ms Andersen was present in the court, and asked whether he had anything to say to her.
“I don’t think this will be the forum for that.” he said.
Though Hosking clarified that he would be happy to meet the family privately, Ms Andersen struggled to hide her hurt.
“Today was sorry day, and he didn’t say sorry,” she said.
As this latest round of inquest hearings has taken its course, they've been characterised by that same feeling of disappointment.
When the process started back up after a two month delay, the family’s focus had been on what occurred during a fatal 125-second-trip during which Morrison was moved in a prison transport van to Yatala Labour Prison’s High security G-Division.
Inside the van
Of the seven officers that escorted Morrison during that trip, five - Trent Hall, Darren Shillabeer, Liam Mail, Martin Crowe and Jean-Guy Townsend - were present with him in the back as he lay face-down in a spit hood, with his wrists and ankles bound.
There is no CCTV footage of the van's interior for that period.
The family has since started a petition calling for a ban on spithoods, which has garnered over 20,000 signatures.
Initially, lawyers for the guards attempted to have them all appear on the same day in order to claim “penalty privilege” - a legal protection that allows witnesses at an inquest to refuse to answer questions where they may incur criminal or civil liability - as a group.
While the law has been changed to allow Coroners to compel testimony of witnesses in South Australia, it does not apply retrospectively to Mr Morrison's inquiry.
When the officers were made to appear one-by-one, most claimed privilege in an effort to avoid answering questions. When they did answer, they often “could not recall” the events in question.
The words “I don’t recall” appear at least 597 times, and “privilege” appears 1603 times, across more than 7342 pages of transcript from 71 days of hearings.
Dysfunctional prison environment
What evidence has been heard to date has since painted a picture of a dysfunctional prison environment where corrections officers were untrained, resistant to change and frequently in conflict with management.
Senior officers have sought to present prison management as absent and indifferent. The coroner has also heard how a view had formed among prison management that officers Shirley Bell and Michael Griffith “ran interference” in the aftermath of Mr Morrison’s restraint.
'Misappropriation of medical terminology'
Where the guards have discussed the events of the day, they have focussed on the initial incident that lead to Mr Morrison’s restraint describing him as suffering from “excited delirium”, a state where a person is allegedly acting aggressively, possessed of great strength and immune to pain.
The state “Excited delirium” is not a medical condition recognised by the World Health Organisation or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which defines psychological disorders but has been relied upon primarily by US law enforcement in situations where a person has died in custody - including in the case of George Floyd.
A report by US think tank the Brookings Institute from August 2020 describes the term as “a misappropriation of medical terminology” and found it was disproportionately applied to Black people in interactions with law enforcement.
Other evidence has focused on the aftermath, with the coroner hearing from a taxi driver who picked up one of the guards on the night of Mr Morrison’s restraint.
He came forward earlier this year after seeing a report on NITV, saying he overheard guards discussing tampering with evidence.
No CCTV footage
Meanwhile, Department of Correctional Services (DCS) official Keith Timmins - who works in head office and was not at the prison on the day - told the court how the CCTV footage in the prison transport van does not exist as it was obstructed by the head of a prison guard who “would have been” in the process of physically holding Mr Morrison down.
This material has punctured the narrative presented by DCS chief executive David Brown in his appearance on Monday.
Though Mr Brown accepted there had been multiple failures of policy and procedure, from the initial admission of Mr Morrison to the treatment of his family before his death at the Royal Adelaide Hospital on 26 September 2016, he refused to be pinned down.
In one instance, Mr Brown was told about previous evidence that half the guards at Yatala Labour Prison at the time of Morrison’s death did not have current first aid training and none had current CPR.
When asked a direct question by the Coroner about this, Mr Brown said he did not support standing down staff whose training was out of date on the basis it may leave the prison understaffed.
“Honestly, in any [prison] there’ll always be a small number of staff whose competence has lapsed,” Mr Brown said.
In another set of questions, Mr Brown confirmed that none of the officers involved in Morrison’s restraint had faced disciplinary action and that he was not considering taken any future action.
'Slippery and sly'
For the family, none of this comes as a surprise.
Ms Andersen says that from the beginning the department has been “slippery and sly” in how they have dealt with the matter, even down to the language they used to describe what happened.
“They keep talking about Wayne’s ‘medical emergency’,” Andersen says.
“It’s something they are slinging about to divert the attention from what happened and it’s their way of justifying the way they treated Wayne.
“From his intake through to treatment, carried on through to the restraint, the way they carried him to the van, and pulled him out onto the floor of G-division - they keep talking about him as just a prisoner who assaulted their work colleagues, and Wayne paid for it with his life.”
The inquest continues on Thursday with the pathologist expected to give evidence about the cause of death.