Coroner blasts prison staff after man's death
A coroner has slammed prison staff and the lack of CCTV after a man died after being bashed in a Victorian prison four years ago.
State coroner Judge Ian Gray was scathing of staff from the company that operated Fulham Prison, GEO Group, saying their behaviour on the night Colin Johnson was bashed was "unacceptable".
Judge Gray also criticised the procedures at the prison which led to a six-hour delay before it was discovered that Mr Johnson had suffered severe head injuries.
The comments were contained in a part-redacted finding handed down on Friday.
Mr Johnson, 53, was serving a two-year sentence at the medium and minimum-security prison when he was bashed with what was believed to have been a wooden rolling pin.
A notoriously violent prisoner then housed at Fulham is suspected of carrying out the attack but has never been charged.
Tragically, Mr Johnson had been favourably considered for parole but was denied after he returned a positive drug test.
Described by his family after his death as a "loving son" who should have been safe in jail, Mr Johnson battled heroin and alcohol addiction since his late teens.
He was discovered unconscious in his cell just before midnight on April 23, 2011.
He was naked and bent over on his knees, the right side of his face was covered in blood, and he had extensive head injuries.
He was taken first to a hospital in Gippsland and then to the Alfred Hospital in Melbourne where he was placed on life support. He died on May 6 without regaining consciousness.
Guards in nearby room did not see attack
Mr Johnson was housed in the Yeerung Unit of the prison, which consists of two "pods" separated by the guard room.
Each pod comprises a number of cells, a laundry, kitchen and a day room.
Judge Gray found that Mr Johnson was assaulted in the pod 1 day room sometime between 5:06pm and 5:49pm.
One prisoner gave evidence that he saw Mr Johnson in the day room holding his head while another prisoner was "cleaning up".
However, none of this was captured on CCTV cameras because neither of the day rooms had camera coverage.
GEO Group gave evidence at the inquest that this was because both rooms were clearly visible from the guard station.
It is unclear why the guards on duty at the time did not see the fatal assault.
GEO Group said in its submission that the guards were likely to have been collecting their belongings prior to locking the prisoners in for the night, and that three of them had been disciplined after Mr Johnson's death over their actions that day.
"It is unacceptable that the correctional officers on duty did not observe the assault on Mr Johnson, the subsequent cleaning up of the area by another prisoner, Mr Johnson walking, injured, back through the common area to the cells, or his injuries at lockdown," Judge Gray said.
Coroner recommends CCTV cameras be installed in day rooms
After he was bashed, Mr Johnson returned to his cell.
At 6:00pm the prisoners were locked down, but procedures at the time did not require Mr Johnson to be "viewed physically, face on", in Judge Gray's words, so his injuries were not noticed.
"After considering the evidence, I am satisfied that there was inadequate observation of Mr Johnson at the point of lockdown. This was conceded by GEO Group and changes were subsequently made to the lockdown procedure," Judge Gray said.
Although GEO Group argued it was "speculative" to say Mr Johnson might have survived if his injuries had been noticed earlier, Mr Gray found that was the case.
"In my view, and on the balance of probabilities, earlier identification of the injury, earlier medical intervention and earlier transportation to hospital would have increased Mr Johnson's prospects of surviving the attack," Judge Gray said.
In the findings, Judge Gray acknowledged GEO Group had made changes to procedures in the wake of Mr Johnson's death, including strengthening the lock-up muster procedure, improving patrols in the unit and reminding guards of their supervisory duties when in the guard station.
Judge Gray also recommended CCTV cameras be installed in the day rooms of the Yeerung Unit.
A spokesperson for the GEO Group said the coroner's finding highlighted that changes had already been implemented by GEO to address problems in the centre's security procedures.
