The West Australian Coroner has given his findings in the case of a man who was effectively cooked to death in the back of a prison van.

Last January an Aboriginal elder known as Mr Ward was being driven in the back of the van through the searing temperatures of The Goldfields.

The air-conditioning unit was not working and the temperature inside reached 50 degrees Celsius.

Before he died, the 46-year-old from Warburton suffered third-degree burns where his body touched the hot metal floor.

Coroner Alistair Hope handed down his long-awaited findings on Friday.

Mr Hope said Mr Ward died as a result of heat stroke which was caused by grossly excessive heat in the pod in the transit van taking him from Laverton to Kalgoorlie.

He said Mr Ward suffered a "terrible death" that was "wholly unnecessary and avoidable" and he died as a result of a "litany of errors".

He accused the people driving the prison van of collusion and giving false evidence.

He also said the fact the prison van did not have a spare tyre was an indication of the transport company's "reckless" approach to prisoner safety.

He said it was a disgrace that a prisoner in the 21st Century, particularly someone who was not convicted, was transported such a distance in such a compartment.

The Coroner expressed his disgust at the state of the compartment, saying it had all-metal surfaces, very little light, and no restraints to protect the person inside if the vehicle had come to grief in some way.

There was a lack of air flow and there was no proper method of communication between the pod and the drivers.

He said there was a panic button in the back but it was not prominent and only set off a light in the driver's compartment which could not be seen in daytime.

The fan did not work when it was tested, the air-conditioning was not working, and in any case the air-conditioning was not appropriate to be driving people such long distances in remote areas.

He said it was difficult to imagine a more uncomfortable environment.

West Australian Attorney General Christian Porter has called the incident tragic and avoidable.

Mr Porter says he expects Mr Ward's family will apply to him for a compensation payment but would not say how much would be offered.

He also has not ruled out a $100,000 contractual penalty against the prison transport company, GSL.

"The contractors have moved those two employees from Kalgoorlie to Perth, and they are no longer involved in prisoner transport," he said.

"Perhaps if that $100,000 penalty was applied, that might go to Mr Ward's family in the nature of a compensatory payment."

Arbitrary and inflexible

The Coroner said there were two pods on the vehicle; one directly behind the cabin, which was not so bad - there was cushioning on the seats and there was the possibility of opening windows.

But there was an "arbitrary and inflexible" rule that all prisoners should be considered high risk in the case when there is only one person being transported, and should be placed further away from the cabin.

In their evidence, the officers driving the van had said that they thought the air-conditioning was working.

No action was taken against the officers by their company GSL.

A GSL representative said they had not broken any of the procedures or rules.

The officers said they did not know why they did not check on Mr Ward during the four-hour journey.

When they heard what sounded like a fall, when Mr Ward hit the bottom of the pod, they realised that something was wrong.

The Coroner said that it appeared that Mr Ward died fairly early in the trip because he was given around 600mls of water to drink and there was still some water in the bottle when he was found unconscious in the back of the van.

Some GSL staff had been complaining for some time that the vehicles were not roadworthy for such long distances.

Dennis Eggington from the West Australian Aboriginal Legal Service says the Coroner conducted a thorough investigation into Mr Ward's death.

"His investigation and findings have proven that there's alot to be answered and people really need to be aware there are a couple of departments that have got blood on their hands at the moment," he said.