Seven prison officers yet to provide a statement on what happened in the van during the journey with Morrison

Unusually for a coronial inquest, the family of Wiradjuri man Wayne Fella Morrison does not know what the evidence is going to show.

They have the witness schedule and a rough outline of events. They have read the brief. They know that the inquest, which began at the Adelaide magistrates court on Monday, is expected to run until 28 September and possibly for several more days in December, if the deputy state coroner, Jayne Basheer, decides she needs more time to hear all the evidence.

But they don’t know what the seven prison officers who travelled with Morrison during a three-minute journey on a prison transport van on a Friday three days before he died - during which he turned “blue and unresponsive” – are going to say.

Those seven officers are among nine who have yet to give statements about the incident to SA police, almost two years after it occurred.

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Morrison died at Royal Adelaide hospital at 3.50am on 26 September 2016. He had been in a coma since leaving that prison transport van.

He had been in custody for just seven days and was facing domestic violence charges but had never been convicted of an offence in SA.

His mother, Caroline Andersen, told the inquest on Tuesday that she was disappointed the officers riding in the back of the van had “blatantly refused to come forward and give any evidence or tell us what actually happened”.

In his opening address, the counsel assisting the coroner Anthony Crocker said there were several impediments to the initial police investigation, including a failure to separate witnesses, that “raise the issue of potential contamination let alone any risk of collusion”.

The short van journey occurred moments after Morrison had been restrained by up to 14 guards, after allegedly assaulting two guards in a holding cell and injuring three others.

He had been handcuffed and his legs were tied together. A spithood was placed around his head.

Video played in court on Monday showed him being carried, face down, out of the prison and then placed, again face down, on the floor of the van to be moved to another unit.

There is no CCTV footage of the van journey. The only person to give a police statement about those two minutes and 55 seconds was the driver, who said, according to Crocker, that he did not notice anything untoward in transit – no sounds of a commotion or the feeling of the van rocking on its suspension. Through the CCTV relay, which displayed only in real time, he could see the back of a prison officer’s head but nothing else.

The court has heard nothing to suggest Morrison was assaulted in the van.

Crocker said that when the prison officers noticed Morrison did not appear to be breathing, they pulled him out and rolled him on to his side to remove the restraints. They called a “code black” for a medical emergency and collected an oxygen mask, but did not begin CPR until apparently told to do so by a doctor three minutes later.

Morrison was revived by paramedics once an ambulance arrived, but Crocker said he was without spontaneous circulation for more than half an hour.

Morrison’s sister Latoya Aroha Rule told the inquest he had been registered under a false name at the Royal Adelaide hospital. Rule said she and her family were prevented from seeing him for several hours by hospital staff, who claimed he had not been admitted, despite knowing that was not true, and were at one point taken out of the hospital to the car park by security officers.

Even after they were allowed to Morrison’s bedside, Andersen said, they were “always being watched”.

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An autopsy conducted by two independent doctors found that Morrison suffered a hypoxic brain injury and multiple organ failure after experiencing a heart attack. The cause of the heart attack, said Crocker, was “likely to be multifactorial with possible factors including the psychological and physical stress relating to the initial aggression and subsequent restraint of Mr Morrison, restraint asphyxia, positional asphyxia in respect of how Mr Morrison was transported in the van, [and] asphyxia related to the spit mask”.

Crocker said the police “expressed concern that their ability to investigate the cause and circumstances of Mr Morrison’s death has been adversely affected by the actions of some prison officers”.

Those actions included denying police entry to the prison for several hours; prison guards involved in the incident leaving the site and going home before giving a statement; incorrectly claiming that other prison guards had left when they remained on site; and remaining grouped together.

Since the royal commission into Aboriginal deaths in custody in 1991, all deaths in custody must be investigated as a possible homicide in the first instance, and subjected to a mandatory public inquest.

The court is expected to examine the decision to block police from establishing a critical incident base in the prison; adequacy of written prison records; and the possible need for more CCTV cameras.

It will also examine the adequacy of prison officer training around mental health, transport of difficult prisoners, first aid, and the risks associated with positional asphyxia.

The inquest continues on Monday.