'Litany of failings' in Indigenous death in custody

A coroner has pointed to a "litany of failings and shortcomings" in the management of an Indigenous man who died after an altercation with prison officers while in custody in South Australia.

Deputy Coroner Jayne Basheer says the death of Wayne Fella Morrison cannot be directly attributed to the restraint applied to the 29-year-old during the incident at Adelaide's Yatala Labour Prison in 2016.

Ms Basheer has ruled that he died as a result of brain damage and multi-organ failure after suffering a cardiac arrest while under psychological and physical stress and exertion.

But she also found Mr Morrison had pre-existing heart disease.

"No single factor or mechanism can be identified as the sole underlying cause or explanation for Mr Morrison's cardiac arrest," the coroner said in her findings on Friday.

"The potential causes are multifactorial in nature and include the effects of marked physical exertion, emotional and psychological stress and underlying coronary artery disease."

Ms Basheer  did not make any adverse finding against the guards involved in the prison incident and said the level of force used was reasonable, necessary and not excessive.

She said their conduct must be considered against the whole of the evidence which included glaring deficiencies in the training of correctional officers at Yatala Labour Prison which were exposed when they were called on to manage a major incident.

"The evidence has revealed a litany of failings and shortcomings at every stage of Mr Morrison's management whilst he was in the care and custody of the Department for Correctional Services," the coroner said.

"The evidence has also demonstrated that in an operational crisis the management team was unable to co-ordinate and effectively manage the post-incident response."

Before his death, Mr Morrison had been held in custody on an assault charge after being refused bail.

The altercation with prison officers came as he was being taken for a court appearance by video link.

Once restrained, he was lifted into a van and placed face down but was blue and unresponsive when he was pulled out.

Despite resuscitation attempts, he did not regain consciousness and died in hospital three days later.

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