Critical Report into the Death in Custody of Mr Morrison is Released

Last Updated on 10/09/2020 by National Justice Project

The SA Ombudsman has handed down a damning Report into issues surrounding the 2016 death in custody of Mr Wayne Fella Morrison (named with family permission) and the way the South Australian Department for Correctional Services (the Department) failed to provide critical information about his health and welfare to his family. Mr Morrison’s mother and extended family have been waiting four years for the inquest into his death to be completed and they want to hear the truth about what happened to him at the hands of the prison system before he died.

The Ombudsman also criticised the way Mr Morrison’s family were treated whilst he lay in a coma in hospital and the Department’s lack of transparency.

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Mr Morrison died in hospital on 26 September 2016, three days after an incident at Yatala Labour Prison, where he had been restrained with handcuffs, ankle flexi-cuffs and a spit hood, and then placed face down in the rear of a prison transport van. Seven prison officers, including the driver of the van, accompanied Mr Morrison from the holding cells to the high security section of the prison and were present when Mr Morrison became unresponsive.

The Inquest into Mr Morrison’s death began in 2018 and is still running. In 2019 a number of prison officers took legal action against the Coroner to stop her from asking certain questions about the incident, arguing that officers should be able to claim a privilege against giving evidence where they may be subject to a penalty. They also tried to prevent the Coroner continuing to hear the matter, arguing unsuccessfully that she should not hear the inquest herself because of apprehended bias. The inquest could not continue this year because of Covid concerns and will now resume in 2021.

The Ombudsman’s Report does not cover the lead up to Mr Morrison’s death at Yatala Prison or the death itself which is still the subject of a lengthy coronial inquest – rather the focus of the investigation has been on the Department’s administrative practices before and after the incident at Yatala Prison.

The Ombudsman’s Report identified nine key issues with the Department’s administrative procedures arising from Mr Morrison’s death and was largely critical of the way the Department handled the situation.

Considering there was no video of the time Mr Morrison spent in the van transporting him within the divisions of  Yatala, the Ombudsman found, By transporting Mr Morrison to G Division in a van without recording capacity, the Department acted in a manner that was unreasonable”. In addressing this, the Ombudsman recommended that all prison vans be fitted with video recording equipment and, failing that, video be made using hand-held cameras. More broadly, the Report recommends body cameras be worn by all corrective officers in all SA prisons.

Mr Morrison was a first-time prisoner being held in remand in South Australia’s highest security prison due to overcrowding of the prison system.  As a first-time Aboriginal prisoner Mr Morrison should have been identified as a person at risk. The Ombudsman added that the Department failed to recognise that, as a person at risk, Mr Morrison should have been monitored and handled appropriately during the five days he spent in the prison. The Ombudsman recommended changes to procedures including an electronic warning system whereby an at-risk prisoner is electronically flagged at all times. For its multiple failures the Ombudsman recommended the Department apologise to Mr Morrison’s family.

The Report was critical of how the Department dealt with Mr Morrison’s family, stating, The Department’s failure to provide Mr Morrison’s family with sufficient information and support was wrong”. In addressing this finding the Report recommends the Department “Formally apologise to Mr Morrison’s family for its failure to facilitate the provision of appropriate information and support”, and for “failing to appropriately identify Mr Morrison as an at risk and to monitor and review his welfare accordingly”. Compounding these errors by the Department, the Report also criticises the failure of the Department to provide appropriate access to the Mr Morrison while he lay in a coma and when the decision came to turn off his life support. During this time the family had restricted access. The Ombudsman reminded all Departmental officers to treat family members with “dignity, respect and sensitivity at all times”. Mr Morrison’s mother, Ms Caroline Andersen, has been consistently calling for an apology from the Department for the past four years.

The Ombudsman was also critical of the Department’s:

  • Failure to raise a Notification of Concern and to identify Mr Morrison as an ‘at risk’ prisoner on his admission to Yatala.
  • Failure to identify Mr Morrison as an Aboriginal person.
  • Failure to maintain records in accordance with the State Records Act
  • Failure to respond to health concerns raised by family members, Caroline Andersen and Latoya Rule, who stated that “the main thing we were trying to get across was that Wayne needed medical help…he had spent all night sick [in custody] and the police refused to get a doctor in for him.

Many of the Ombudsman’s recommendations echo those of the 1991 Royal Commission into Aboriginal Deaths in Custody, prompting the family to hold the view that Mr Morrison would be alive today if those recommendations had been properly implemented over the past 30 years in South Australia.

The lack of transparency by the Department and the lack of information provided by the officers who transported Mr Morrison within the prison, where he was alive when placed in the back of the van and was unresponsive and not breathing minutes later when the van arrived at G Division continues to torment his family. Mr Morrison’s mother, her family and the entire Aboriginal community want answers – they demand justice and accountability for Mr Morrison’s death and continue to wait for the findings of a Coronial inquest which is now delayed into 2021.

In the days leading up to Mr Morrison’s being declared dead in the hospital, his family were continually unable to access correct information regarding the location and status of their son and loved one. When the family were notified that Mr Morrison was in the Intensive Care Unit on life support, his sister recalled that “hospital staff turned my mother away and said Wayne was not present… I grew further suspicious of the circumstances occurring.”


Caroline Andersen, Wayne Morrison’s mother said, “I thank the Ombudsman for looking into Wayne’s death and understand, that with certain restrictions, he can only go so far. This has been an awful process for a mother extending over four long years, and I still have no clear answers to what happened to my son in the back of that prison van. “

With all the delays in getting to the bottom of my son’s death some changes are required to the law to ensure that parents like me get answers sooner.”

An apology is not enough, but it is the right thing to do. It is the beginning of acknowledging that they had a duty to care for my son and that they did wrong to him. As a mum, I want to know why these guards are still working inside the prison system when there are so many unanswered questions.”

I want to know the truth and I want accountability

Spit hoods are banned in all other States and Territories and I believe that spit hoods should be outlawed in South Australia. Just last week we saw an African American man in a spit hood die in in police custody in the United States.”

The Ombudsman found that the Department was not transparent in failing to draw his attention to missing pages in their investigation report and the lack of transparency is something that Mr Morrison’s mother is also complaining about. She points to the lack of CCTV recordings of critical events and she wants the department to tell her what happened to her son during his last moments in the prison. She said, “The Department were responsible for my son and it’s their job to know what happened to him.


Latoya is Mr Morrison’s sister. She is a strong advocate for justice for Aboriginal people who have died in custody. She said about the Report,  “In light of the Black Lives Matter movement, and ongoing global protests regarding unlawful use of force in restraint processes, it is disappointing that the physical role of correctional officers in my brother’s death has been deemed outside the scope of investigation in this report. In saying that, I believe this report stands somewhat as an accountability measure of SA Corrections and its Chief Executive Mr David Brown, in the absence of transparency for my family and hence, I thank Mr Lines for his professional inquiry. I do not accept Mr Brown’s reluctance in this report to acknowledge that the Department’s dealings with my family have been disrespectful. I hope that the forthcoming apology to my family by Mr Brown and the Department will be genuine.”


Director of the National Justice Project, George Newhouse, emphasised similar concerns.

Mr Newhouse said, “Mr Morrison is one of the 440 Aboriginal deaths in custody since the end of the royal commission into Aboriginal deaths in custody in 1991. At least the Ombudsman has slammed the conduct of the Department, and quite rightly so. They were responsible for Mr Morrison’s care when in custody and they let him and his family down.”
“I appreciate that an apology from the Department is a good start but is not meaningful without accountability and real change including the implementation of all the Royal Commission into Aboriginal Deaths in Custody Royal recommendations and the banning of spit hoods. Our sympathies are with Mr Morrison’s mother, his siblings and his entire family