LIZ JACKSON: It was Australia Day, 2008. A hot Saturday night when the Laverton police in the Western Australian Goldfields pulled over a car on the back roads.

There was they said nothing unusual about the way it was being driven, but they breathalysed the driver. He was arrested for driving under the influence of alcohol.

The following morning he was put here, in this van, to be carted to Kalgoorlie gaol by a private security firm.

Four hundred kilometres though the blazing heat of the day. Outside the temperature reached 42 degrees, inside the surface of this metal cell steadily increased to over fifty-six.

By midafternoon, the Aboriginal man in custody was dead.

Mr Ward had died a slow and shocking death.

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: My goodness sake, one can only feel such horror at slowly being cooked.

JAN TURNER, ANTHROPOLOGIST AND FRIEND: It's the unspeakable. It's the unimaginable to me.

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: It's a death that didn't need to happen and it's a death that shouldn't have happened.

DAISY WARD, MR WARD'S COUSIN: Why did they do that to my cousin?

LIZ JACKSON: Tonight on Four Corners "Who killed Mr Ward?"

(On Screen Text: Who Killed Mr Ward? Reporter: Liz Jackson)

LIZ JACKSON: The township of Kalgoorlie, three weeks ago.

It's the last days of the Coronial Inquest into Mr Ward's death, held at the Kalgoorlie Court House.

His family members have travelled in from the remote north eastern communities of Warburton, Tjuntjuntjara, Patjarr and Warakurna.

Between 500 and a thousand kilometres away.

His widow Nancy, and their children, his cousins and friends, his sisters and brothers, and his mother, they're desert people from the Ngaanyatjarra lands.

As part of custom they've requested that Mr Ward's first name not be used.

(Excerpt of footage of Mr Ward's family, 1965)

Mr Ward was himself born in the Western desert. His family, seen here, was amongst the very last to leave their traditional way of life.

This film was made in 1965.

His father was Tjakamarra.

FILM NARRATOR: Tjakamarra of the Marundinjiyara linguistic group of the Western Desert is camped at Baddya with three of his four wives and seven children.

LIZ JACKSON: One of the youngest of the seven children, Mr Ward is seen being carried by his sister Dunera, he's aged around three.

FILM NARRATOR: One of the elder girls, Dunera, with her young brother on her back, picks up a firestick and off they set.

LIZ JACKSON: This is his mother, Katapi.

FILM NARRATOR: Katapi starts gathering the seed. The whole seed head is pulled off. Mannuba and her daughter watch the others working.

Katapi has a circle of emu feathers to help her balance her 'biddy'

LIZ JACKSON: Mr Ward, called Nampukutji, is on his mother's lap.

FILM NARRATOR: Nampukutji, sucks Katapi's breast as she works.

(End of Excerpt)

LIZ JACKSON: The same year this footage was shot, the family moved from the desert, to the more westernised life in the remote community of Warburton.

Four decades later, the suckling toddler was Warburton's Community Chairman, and employed in the management of the nine million hectares of the Ngaanyatjarra Lands.

(Excerpt of footage of Mr Ward)

MR WARD: And we are the decision makers who are working with the Government.

(End of Excerpt)

LIZ JACKSON: He was educated, well respected and a friend of the local sergeant.

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: He had a very good grasp of the English language and could communicate with people from, anyone from you know the Ministers, Federal Ministers, through to mining companies, people who just wanted to ask questions about the different history of the Aboriginal people out in the Ngaanyatjarra Lands.

LIZ JACKSON: And someone you regarded as a friend?

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: Definitely, yeah definitely a friend.

JAN TURNER, ANTHROPOLOGIST AND FRIEND: So really in the space of his lifetime, he had gone from a completely traditional sort of way of living, to being able to go to China and represent his people in China on land management or to talk in Parliament House to politicians and he was very proud of it, so he called himself the last of the stone age men.

LIZ JACKSON: The community of Warburton and the surrounding lands are dry.

The nearest legal drink is a 600 kilometre drive down here to Laverton, and having gone that far, many people have more than one.

(Excerpt of footage of people at night in Laverton)

Saturday nights are busy nights for the Laverton police, especially in the summer months, the holiday period.

(End of Excerpt)

JAN TURNER, ANTHROPOLOGIST AND FRIEND: This period late December - January is a time when people do go to Laverton and they do get very drunk, if you're a drinker and often its binge drinking.

LIZ JACKSON: On the Australia day week-end, Mr Ward was in Laverton, drinking and driving.

According to the evidence given at the Inquest he was mostly driving on unsealed bush tracks, near the community on the outskirts of town.

But when he was breathalysed, he was four times over the limit and it was not his first offence.

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: It's not a thing that makes this person a big bad person. He's a person that went down and drank too much and drove too much. He didn't drive too much, he drove. And that's typical of many people in Sydney, Melbourne, Brisbane, Perth, everywhere.

LIZ JACKSON: What's not so typical in Sydney, Melbourne, Brisbane and Perth are the events that followed.

(On Screen Text: Reconstruction)

Mr Ward spent that night, locked up in a police cell. While he was asleep the Laverton police called the GSL private security firm.

They booked a prisoner transport van to collect Mr Ward the following morning to cart him off to Kalgoorlie jail.

This was before they even called the Justice of the Peace, who legally needed to consider first whether Mr Ward should instead be given bail.

The JP Barrye Thompson told us he knew nothing about this.

BARRYE THOMPSON, JUSTICE OF THE PEACE: I certainly wasn't aware of that, that there'd been a pre-booking, (laughs) I certainly wasn't. And the first I knew.

LIZ JACKSON: But you.

BARRYE THOMPSON, JUSTICE OF THE PEACE: The first I knew was a phone call at nine o'clock in the morning.

LIZ JACKSON: What would you have thought about the fact that there'd been a pre-booking?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Um, I would've been a little disappointed.

LIZ JACKSON: Because what does that indicate to you?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Well that you know sort of that they've made prearrangement, you know, sort of ah. And to me what was going to happen depended on my decision on the assessment of the cases.

LIZ JACKSON: The JP did convene a bail hearing the following morning. He conducted it standing at the door of Mr Ward's police cell.

Ward was asleep when the JP arrived but the police woke him up and the charges were read to him.

He wasn't asked if he wanted a lawyer, and bail was refused, it took about ten minutes.

LIZ JACKSON (to Barry Thompson): Is that a properly constituted bail hearing?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Um.

LIZ JACKSON: Is that fair?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Well put it this way I, I presumed it was. I, I and other JPs had done that, particularly when the people had been severely intoxicated or may have been violent and it was easier for the police to control them whilst they had them in the cell. But this.

LIZ JACKSON: But he wasn't a violent person.

BARRYE THOMPSON, JUSTICE OF THE PEACE: No, well he thi-this person wasn't violent, no I must admit.

LIZ JACKSON: And he was, he was asleep when you arrived.

BARRYE THOMPSON, JUSTICE OF THE PEACE: Yes.

LIZ JACKSON: And he was woken up and it was a

BARRYE THOMPSON, JUSTICE OF THE PEACE: Yes.

LIZ JACKSON: Ten minute hearing.

BARRYE THOMPSON, JUSTICE OF THE PEACE: Yes, yes.

LIZ JACKSON: Is that the way you'd like your bail to be considered, to be woken up and have a 10 minute hearing?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Um it's not unusual. I mean if, if.

LIZ JACKSON: But is it fair?

BARRYE THOMPSON, JUSTICE OF THE PEACE: Fair to whom?

LIZ JACKSON: To the prisoner?

BARRYE THOMPSON, JUSTICE OF THE PEACE: The prisoner's. What, so you should think that the um, he should be wait, wait until about 12 noon until the person decides to wake up? Well I thought 10 o'clock in the morning's a reasonable time to be woken.

LIZ JACKSON: When Mr Thompson later gave evidence, at the Inquest he revealed he hadn't actually done the JP's training course, but was instead relying instead on a booklet, which he'd not fully read.

He couldn't remember what it said about considering bail.

There were good arguments for and against. Mr Ward had breached bail on previous occasions, but then again he had strong community connections.

Mr Thompson did not consider them.

LIZ JACKSON (to Barrye Thompson): So did you consider his local connections? Did you know that he was a well respected.

BARRYE THOMPSON, JUSTICE OF THE PEACE: No, no.

LIZ JACKSON: You weren't made aware of the fact that he's a cultural elder in.

BARRYE THOMPSON, JUSTICE OF THE PEACE: No.

INTERVIEWER: Warburton. Well respected, well connected.

BARRYE THOMPSON, JUSTICE OF THE PEACE: No. No. He was an Aboriginal in a very drunken state or very groggy state. That's all I knew him as.

LIZ JACKSON: The following morning the weather forecast predicted a scorcher.

The GSL Mazda van arrived at about 11.20, to take Mr Ward on the long drive to Kalgoorlie jail.

The transport guards in the van were Nina Stokoe, and Graham Powell.

Nina Stokoe was new in the job, in the statement she read at the Inquest she described Mr Ward like this.

EXCERPT FROM STATEMENT: He was a man in his 40's, 50's, Aboriginal with a dark skin. He was dirty.

LIZ JACKSON: Graham Powell on the other hand was GSL's most experienced guard, but six months before he'd been suspended from his supervisors job.

Company documents submitted to the Coroner gave as a reason, his admission that he knew of:

EXCERPT FROM DOCUMENT: Racial slurs directed at prisoners, he knows it goes on and allows it. In fact he states that he participates in it.

LIZ JACKSON: The GSL guards were told by the Laverton police that Mr Ward would be no trouble, that he was compliant.

The police gave Ward a frozen pie and 600 mls of water for the trip.

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: The police officers who were dealing with Mr Ward were officers who knew him.

LIZ JACKSON: So they knew him as basically what you're saying, a good bloke?

NEIL GORDON, SENIOR SERGEANT WARBURTON POLICE AND MR WARD'S FRIEND: Yeah. Yeah.

LIZ JACKSON: At around 11.30, Mr Ward stepped into the rear pod of the van, and into the care of GSL.

Evidence was given, he remarked as he entered how warm it was in there.

(Excerpt of footage of back of van)

There's no natural air flow that reaches back here, the only window is this one, and it's closed and covered with mesh.

If the prisoner wants to communicate that he's in distress, there is a small unmarked duress button by the back door.

But the guards could not remember telling Mr Ward about it.

(End of Excerpt)

EXCERPT FROM GRAHAM POWELL'S STATEMENT: I just can't remember whether we did or we didn't discuss it.

LIZ JACKSON: The guards headed out on what they knew would be a long journey through the heat of the day.

Its 400 kilometres to Kalgoorlie jail.

The Mazda van was old and slow, as Nina Stokoe put it.

EXCERPT FROM NINA STOKOE'S STATEMENT: Every-one agreed the vehicles were crap.

LIZ JACKSON: Nina Stokoe had filled in GSL's vehicle check list earlier that morning, but there was no box to tick to say the air conditioning had been checked.

At the inquest Mr Powell was asked:

EXCERPT FROM INQUEST: Didn't you think it would be highly dangerous not to check the air-conditioning?

EXCERPT FROM INQUEST, GRAHAM POWELL: Yes, I will agree with you.

LIZ JACKSON: Both guards knew there had been ongoing problems with this Mazda's air conditioning unit.

That just recently it had broken down but as the day wore on and the temperature rose, neither suggested stopping to check Mr Ward in the back.

The air con unit in the front where they were sitting, was on a different system, and it was working fine. But the fan motor that should have cooled the rear pod had failed.

(Excerpt of photographs of the vans failed fan motor)

These photographs were evidence at the Inquest, they show a plastic bag had become wrapped around the motor shaft and it was rusty, dusty and clogged with string.

(End of Excerpt)

The Coroner's expert was Gavin Lyons.

GAVIN LYONS, CORONER'S EXPERT: There would've been signs that the motor was going to fail several weeks before it failed. The fan would've slowed down, it would've gotten noisy before it finally failed.

LIZ JACKSON: It was common for guards to stop on a long haul trip like this, for petrol, food and water, and to see if the prisoner needed the toilet, but there was nothing in GSL's written procedures that said that this must be done.

This time they just drove on and on.

A re-enacted journey for the Inquest showed the temperature in the rear pod rising steadily hour by hour, for the last three hours it was over 47 degrees and the surface of the metal cell reached a scorching fifty-six.

There was a CCTV camera for the guards to monitor the prisoner in the back, but Nina Stokoe had noted in the check list that it was not good.

She said at times she could see Mr Ward on the floor, and thought he was asleep.

The range of vision Powell agreed was limited and blurred.

EXCERPT FROM INQUEST: It's impossible to tell, looking through the CCTV, in your experience in that Mazda, whether a person lying down in the rear of the pod is resting, asleep or sick?

EXCERPT FROM INQUEST, GRAHAM POWELL: Correct.

LIZ JACKSON: The guards gave evidence that as they approached Kalgoorlie they heard a thud from the rear of the van.

Nina Stokoe said she saw Mr Ward slump from the seat to the floor. They pulled over.

When the drivers gave evidence Nina Stokoe said she could see Mr Wards head down by the grate, she banged on the door but he didn't wake up, she said she noticed it was really hot, and he was sweaty.

Graham Powell said he didn't remove Mr Ward because it was against GSL policy to remove anybody from a prisoner compartment unless they were in a secure area.

Powell said he tried flicking water on Mr Ward, while keeping the inner door on a chain, there was no response.

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: We don't' treat animals like that. We don't treat our pets like that. We don't treat other animals like that. People get put in jail for treating another, another creature the same as Mr Ward was treated.

LIZ JACKSON: The guards drove they said as fast they could to Kalgoorlie Hospital calling GSL on the way.

Hospital emergency staff rushed out and around to the back of the van.

FRANCIS WAKEHAM, NURSE, KALGOORLIE HOSPITAL: Inside the van was extremely hot. You could feel the the heat coming out of the van as it struck us. It was already a very hot day in Kalgoorlie on that day, but the van was certainly hotter than what the day was.

LIZ JACKSON: How would you describe it, from your experience?

FRANCIS WAKEHAM, NURSE, KALGOORLIE HOSPITAL: Almost like walking into a furnace.

(On Screen Text: Reconstruction)

LIZ JACKSON: Mr Ward was placed in a wheel chair, and rushed into emergency.

His body was limp and he had no pulse, there was a new deep burn on his belly, which had taken off all the skin, and he was hot.

FRANCIS WAKEHAM, NURSE, KALGOORLIE HOSPITAL: We actually packed ice around him. Um we had to take his clothes off and that's when we noticed that there was this nasty burn on the right hand side of his abdomen.

The doctor sort of said "does anyone know how this happened?" Um I was free at this stage so I managed to go out and ask the driver "any idea how the burn might have happened, what was going on?" And they denied any knowledge of it.

LIZ JACKSON: At 4.30 in the afternoon Kalgoorlie hospital declared that Mr Ward was dead.

FRANCIS WAKEHAM, NURSE, KALGOORLIE HOSPITAL: We worked on this patient for nearly an hour and we just couldn't get any life.

(Excerpt of footage of Mr Ward's family protesting)

LIZ JACKSON: Sixteen months later, emotions are still raw.

Mr Ward's family hold this small protest outside the Inquest, so the rest of Australia will know they're still waiting for justice.

MR WARD'S FAMILY: We want justice, we want justice.

LIZ JACKSON: Everything they've heard to date makes their anger stronger.

MALE PROTESTOR: The GSL guards should be charged with manslaughter, what do you reckon?

PROTEST GROUP: Yes.

FEMALE PROTESTOR: She has no husband now, the children, four little kids got no father.

I lost my mother when I was 13-years-old, I was brought with my uncle now and he's gone and I got no-one now.

FEMALE PROTESTOR 2: This is the mother, the mother, she's suffering daily. Justice must be served, changes must happen.

DAISY WARD, MR WARD'S COUSIN: And the person who is responsible from Laverton to Kalgoorlie has to be punished and charged because it's just all, we all crying because our man elder is gone, he left four kids behind and who's going to work for these kids.

So we want changes now. My cousin had to go all the way to China to represent the Ngaanyatjarra people, he did a lot of good things in Warburton and throughout the Ngaanyatjarra lands. He was the next of the elders. Why did they have to do this, didn't do their duty of care.

(Members of the crowd crying)

LIZ JACKSON: What deepens the pain is that every family member grieving here believes absolutely that the answer to that question, why there was no care, is that Mr Ward was black.

(End of Excerpt)

DAISY WARD, MR WARD'S COUSIN: They think they can do anything to black people and like that's what they are thinking to my cousin. We treat black people in another way. Differently, no respect, take them. Oh don't bother worrying for them, just keep driving, keep driving.

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: Actually white fellas wouldn't put up with it. If the long transports in these conditions predominantly involved non-Aboriginal prisoners, it would long ago I believe have been changed.

LIZ JACKSON: Professor Richard Harding was the long time Inspector of Custodial Services in Western Australia. He was a witness at the Inquest.

He's been on a mission for nearly a decade to pressure the State Government to improve prisoner transport.

In 2001, he'd been up in Broome, outside the jail, when he noticed a group of 10 Aboriginal men being unloaded after a journey of over a 1000 kilometres.

They were disoriented, dehydrated and distressed. He was shocked.

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: No opportunity to urinate during the journey, very little access to water, poor climate control, its beyond belief that those conditions were still in existence, and it did strike me even then, that as the overwhelming majority of the passengers were Aboriginal, there was a structural racist element in this, and that's a view that has been certainly reinforced over the years.

LIZ JACKSON: Later that year, Professor Harding produced a report that warned with ominous clarity of the dangers and the inhumanity of the system he'd inspected.

He noted the Department of Justice "has acknowledged problems with providing adequate air conditioning".

He included 2 photos showing the rear pod of a Mazda van, identical to the one into Mr Ward would later be locked.

(On Screen Graphic: Excerpts from Professor Harding's report)

He noted there was "no natural airflow and very little natural light" and when full it was "claustrophobic and cramped".

He stated it was evident that "duty of care issues were taking second place to security" and quoted this pointed comment from a prisoner administrator.

EXCERPT FROM REPORT: The vehicles are not fit for humans to be transported in. We are just waiting for a death to happen.

(End of Excerpt)

LIZ JACKSON: He was disappointed with the Government's response.

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: Well I twice notified the Minister in general terms of my great concern about the health, safety and welfare of the, of passengers in the circumstances of these long transports in which I believe were unsuitable vehicles. Ah but this didn't sufficiently resonate and nothing much was done at the time.

LIZ JACKSON: It was the AIMS company which ran the prisoner transport service then, and owned the same vehicles that are still being used by GSL today.

AIMS was worried by Harding's report, especially in relation to the air conditioning problems.

Unknown to Harding, the AIMS Corporation commissioned its own report, from an air conditioning expert.

Four Corners has a copy.

It's is clear and unambiguous about the type of Mazda used to transport Mr Ward.

(On Screen Graphic: Excerpt from report)

EXCERPT FROM REPORT: These vehicles, were never designed to be operating in the locations that some of them now are.

The proximity of the vehicle to the ground is to low so that it draws an excessive amount of road heat.

The prisoner pod and middle cell are not insulated. The passenger compartment also absorbs heat.

LIZ JACKSON: The report specifically recommends the Mazda's:

EXCERPT FROM REPORT: Are only operated in and around the metropolitan area.

(End of Excerpt)

LIZ JACKSON: This is not on long haul trips in the heat.

AIMS sent the report to the Department of Justice, later to become Corrective Services.

The letter was received in October 2001, but the department did nothing in response.

It was filed away and only resurfaced after Mr Ward had died.

LIZ JACKSON (to Richard Harding): What do you think about the fact that Corrective Services was on notice way back in 2001, that the vehicle was unsuitable for use unless it was in and around the metropolitan area because it drew up heat from the road?

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: Well I mean, it actually makes them criminally negligent, if you could prosecute a bureaucracy, this is what you'd be doing. If there were something called bureaucratic manslaughter, the Department of Corrective Services would certainly be prima facie guilty of that.

LIZ JACKSON: Four years later, AIMS was still running the same fleet of vans, now older and more prone to breakdown.

The big difference was, that the Government now owned them, having bought them cheap from AIMS in 2005.

In October 2006, one of the bigger transport vans broke down three hours drive south of Broome, near the Sandfire Roadhouse, the air con went down with the motor.

Fourteen Aboriginal prisoners were left locked up in the back in small confinement cells for a further eight hours.

The temperature outside went over 40 degrees, inside it was hotter.

It was dark when they left the Sandfire roadhouse, and 20 hours before they finally reached Roebourne jail.

CLIFF HOLDOM, OFFICE OF THE INSPECTOR OF CUSTODIAL SERVICES: About half of them were minimum security prisoners who really a phone call to the prison superintendant would've allowed them out of the vehicle without restraints.

LIZ JACKSON: Cliff Holdom worked with Professor Harding.

He spoke directly with prisoners who'd been locked up in the van. The heat was their main concern, but also a sense of shame.

Two of them were women.

CLIFF HOLDOM, OFFICE OF THE INSPECTOR OF CUSTODIAL SERVICES: It's a camping type potty that is in these cells. That's the only toilet that they had available. So nobody wants, there's too much shame to go to these toilets because.

LIZ JACKSON: Because you go in front of each other.

CLIFF HOLDOM, OFFICE OF THE INSPECTOR OF CUSTODIAL SERVICES: Exactly, exactly. Um and after time of course you know after some hours of confinement you have to go to the toilet. So of course things are getting smellier and nastier and um and sweatier as the day progresses.

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: it is a part and parcel of the sorts of complaints that we have received. But this time we thought that we'd at least get one of our local Green members, Giz Watson, to raise it in Parliament as a real concern.

(Excerpt of footage from Parliament sitting)

MR SPEAKER: Further member statements, the Honourable Giz Watson.

GIZ WATSON, GREENS MEMBER: Thank you Mr President, Mr President I wanted to bring to the attention of the House some information that came to my attention at a meeting I attended with the Executive Committee of the Aboriginal legal Services.

LIZ JACKSON: Giz Watson was the first to make the Sandfire incident public.

GIZ WATSON, GREENS MEMBER: They were not allowed to leave the vehicle at all. And it seems to me, that this is an extraordinary circumstance, which I am sure members won't have heard about via any source other than a statement such as this in the House. It seems to me it's totally unacceptable.

(End of Excerpt)

LIZ JACKSON: It wasn't news to the then Labor Government.

The Minister for Corrective Services, had known for weeks.

LIZ JACKSON (to Margaret Quirk): When Giz Watson brought it up it was in fact no surprise to you?

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: No I was aware of the incident, I became aware of the incident some days after it happened.

LIZ JACKSON: But it wasn't something you chose to make a press release about or let the general public of Western Australia know about it?

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: Well frankly no-one much was interested.

LIZ JACKSON: But the following day there was this.

SPEAKER: The Minister for Corrective Services.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: I wish to inform the house about an incident involving the inter-prison transportation of prisons by the AIMS Corporation.

LIZ JACKSON: The Minister went on to give this commitment, an incident like Sandfire would never happen again.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: It is intolerable that in this day and age people should be treated to such inhumane conditions, and I have requested the Department that we scrutinise existing procedures to ensure that similar incidents do not occur in the future.

LIZ JACKSON (to Dennis Eggington): What did you make of that statement?

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: Well I took it on face value. I mean we have to, I mean we have to put faith in the, in the umpire in the game, we have to put faith in the politicians who do these things.

But um, you know the complaints continued and of course leading to a tragedy. Looking back on it, um I think they were just words in the wind.

LIZ JACKSON: The most chilling response to the Sandfire incident only emerged at Mr Ward's Inquest.

It was a letter written by John Hughes then the general manager of AIMS, now a general manager at GSL.

He was called to give evidence in the last week of hearings.

LIZ JACKSON: Mr Hughes, any chance of an interview with Four Corners?

JOHN HUGHES, GENERAL MANAGER GSL: No comment.

(On Screen Graphic: Excerpts from John Hughes' letter to the Department of Corrective Services)

LIZ JACKSON: John Hughes' letter was addressed to the Department of Corrective Services, it was dated a week after the Minister's assurance that Sandfire would never happen again.

It enclosed what AIMS called its "Strategic Risk Register", which included this particular item of risk "Death in custody - Transport", with the likelihood assessed at "3", on a scale of 1 to 5.

Three means a death is "quite possible", with the associated risk level to the company assessed as "high".

AIMS told the Department bluntly.

EXCERPT FROM LETTER: The identified risks are real and current and present themselves every time a vehicle is in use.

(End of Excerpt)

LIZ JACKSON (to Richard Harding): Do you think alarm bells should have gone off in the Department that there is a risk every day a vehicle is taken out.

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: Absolutely, absolutely. And it's incomprehensible to me why it wasn't treated with greater attention and urgency.

LIZ JACKSON: The Department's bland response to the AIMS assessment that a death was a real and current risk, was this.

(On Screen Graphic: Excerpts from letter from the Department of Corrective Services)

EXCERPT FROM LETTER: Dear John.

I acknowledge your concerns in respect to the aging fleet, in particular the inter-prison trucks used for long haul trips.

As previously advised, a replacement fleet is currently being built.

(End of Excerpt)

LIZ JACKSON: This was spin, the Labor Government had acquired the aging fleet in 2005.

By the date of Mr Ward's death in this van three years later not one cent had been allocated in the State Government's budget to replacing the fleet, despite all the warnings.

Margaret Quirk was the Minister for Corrective Services at the time.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: it didn't happen as fast as I would like it to have happened, but yes.

LIZ JACKSON: Why, why I mean you, you've told me that you're aware that a prison administrator said he was waiting for a death to happen, you've told me you were aware that there was an urgent need to replace the fleet, and yet when it comes before cabinet in a boom time the request for money gets knocked back.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: Well I've thought about this in hindsight, ah um the, ah the fact that so much of this is recurring in remote regions of Western Australia means that maybe people weren't aware of the um, issue as acutely as I was.

LIZ JACKSON: But it's your job to make your cabinet colleagues aware of that.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: Well yes but I'm one of 15 and no one personally ever said to me that there was likely to be a death in the van.

LIZ JACKSON: Well by 2007, you were aware of that because Professor Harding had produced his report and he said that it was the situation with the air conditioning breaking down was a potentially life threatening situation, so you were.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: Well the report had a range of recommendations in it and ah.

LIZ JACKSON: But just to get back to the question, you were.

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: The potential of the air conditioning as we know in hindsight and um no-one regrets what happened to Mr Ward more than I do, and without meaning to sound trite, it was a tragic incident.

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: They were warned and it's happened. And that's the tragedy. It shouldn't have happened.

LIZ JACKSON: Six months before Mr Ward died, the AIMS Corporation bailed out of providing the prisoner transport.

Mr Ward was being driven by guards who now worked for GSL Australia, which had recently been acquired by the private security giant, G4S.

The WA government gave GSL the contract despite the fact that just a year before, this damning report was released.

It concerned the "Inappropriate Treatment of Five Detainees" during an interstate transfer conducted by GSL, in 2004, for the Department of Immigration.

The Investigating officer was Keith Hamburger.

KEITH HAMBURGER, INVESTIGATING OFFICER: I felt quite appalled actually, I um sat in the van, I talked to the Staff as you know that did the escort, I reviewed the evidence.

I saw CCTV footage, and I some of the I've commented in the report that it was ah, yeah I was very shocked by the whole thing.

(Excerpt of CCTV footage)

LIZ JACKSON: This CCTV footage shows just one of the five detainees locked in the back of the GSL van.

It's early in the trip from Melbourne to Baxter detention centre in South Australia.

The detainee is Sayeed Kamal, an Afghan asylum seeker, now settled in Australia.

He's taken off his shirt because it's hot in the cell, and after a while he needs to use a toilet.

But the GSL guards drive nonstop for seven hours, and things get worse.

(End of Excerpt)

SAYEED KAMAL: People was in the backside shouting, crying and ah and I was banging as well because I need to go in the toilet and I bang, bang and no one listening. I heard the officer there driving, they're happy and drive, they're happy to talk with each other, and I can hear him. I can hear him.

But I can't see anything outside. All I can hear him and I heard the other people banging and shouting and um and I was there and I was we be thirsty drinking a little bit of water because I was lucky I was with this guy and I have a water.

And um they didn't stop for any breaks, no lunch, no breaks, nothings and, and I have to like, I have to 'cause I want to go toilet, so I bang and I said "can you stop it because I need to go toilet or smoke cigarette or something?" And they didn't stop for anything. And um and I have to do it in the car.

LIZ JACKSON: Over the seven hour journey, none of the five detainees was given any food.

Only Sayed Kamal and his cell mates had any water to drink.

(On Screen Graphics; Excerpt from report)

GSL was found to be responsible for "placing the health and safety of detainees at risk, humiliation of detainees, disregard of appeals for assistance from detainees in obvious distress".

The report also found the van was "unsafe", there were "faults in the air conditioning system, so it failed to adequately cool the secure compartments".

(End of Excerpt)

LIZ JACKSON (to Keith Hamburger): Did GSL accept that they had breached their Duty of Care in relation to those detainees?

KEITH HAMBURGER, INVESTIGATING OFFICER: Ah that's something you'd have to put to to GSL, but my report outlines the concerns that I found and GSL would have to comment on that.

LIZ JACKSON: They accepted your recommendations.

KEITH HAMBURGER, INVESTIGATING OFFICER: Yes they did yes.

LIZ JACKSON: And paid compensation to the people concerned?

KEITH HAMBURGER, INVESTIGATING OFFICER: They accepted the recommendations and the findings.

LIZ JACKSON: GSL declined to be interviewed by Four Corners, but their public relations officer Mr Tim Hall, apologised back in 2005, and made this commitment, on ABC radio.

(Excerpt of audio from ABC Radio)

TIM HALL, GSL PUBLIC RELATIONS OFFICER: We'll be taking whatever steps we can to ensure even more than we've done already, which is a great deal, to ensure that this can never happen again.

LIZ JACKSON: But it did, and worse. Four years later, this is the same Tim Hall seen here walking into Mr Ward's Inquest.

(Excerpt of footage of protestors and Tim Hall and John Hughes entering the Inquest)

PROTESTOR: You should be ashamed.

LIZ JACKSON: John Hughes is now the general manager for GSL in Western Australia.

FEMALE PROTESTOR: You're the one who was in there, you're part of it, we expect an apology from you folk.

(End of Excerpt)

LIZ JACKSON: Over a year after Mr Ward's death GSL has still taken no disciplinary action against Nina Stokoe and Graham Powell, the guards who drove him on the day.

At the Inquest Mr Hughes was asked why.

His answer was extraordinary.

EXCERPT FROM INQUEST, JOHN HUGHES: I believe the view was formed that they hadn't formally breached any company policies or procedures.

LIZ JACKSON (to Richard Harding): How can it be that you can put someone in the back of a van for a four hour drive on a blazing hot day and not check on their welfare the whole way, and that person die and you not to have breached any of the company's policies and procedures?

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: It's certainly surprising.

LIZ JACKSON: What does it say about those procedures?

RICHARD HARDING, WA INSPECTOR OF CUSTODIAL SERVICES 2000-08: What does it say? It, it tells one that the interaction between the Department which should be ensuring that GSL procedures are appropriate, and GSL itself is not effective and is not actually directed at human rights concerns so much as commercial and technical issues.

LIZ JACKSON: The Commissioner for the Department of Corrective Services declined a sit down interview, but the day after the Inquest finished, he came to Kalgoorlie to meet with the family.

Ian Johnson has been the Commissioner for the past three years.

(Excerpt of footage of Ian Johnson meeting with Mr Ward's family)

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: I'm Ian Johnson, sorry for your loss.

Hi, my name's Ian Johnson, how are you?

GUIDE: This is Dorothy.

Hi Dorothy.

DOROTHY: I'm his sister.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: You're the nieces, hi how are you.

GUIDE: Daisy.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: Daisy, how are you? I'm sorry for your loss Daisy.

There's somebody else still coming?

GUIDE: Yes the wife.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: Would you like me to wait.

GUIDE: Yes.

LIZ JACKSON: They're waiting for Mr Ward's widow, Nancy.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: My name's Ian Johnson, I just want to say sorry for your loss.

LIZ JACKSON; Ian Johnson had a message for the broad family group.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: First of all I just wanted to come along to say I am sorry for what has happened, I feel a bit inadequate no matter what I say, it's not going to change what has happened, so in some ways I don't know what to say.

LIZ JACKSON: He went on to deliver a familiar line, the Department is now committed to ensuring it never happens again.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: To making sure we make the changes to try and ensure this doesn't happen again.

LIZ JACKSON: The family listened politely while he outlined all the recent changes in procedures.

No-one was rude enough to ask why none of this had happened years ago, when Mr Ward was still alive.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: Welfare checks, about obviously safety procedures inside the vehicles, about alarms that actually sound to tell you that something has actually gone wrong, but importantly communicating with people who are being transported to make sure they are alright.

LIZ JACKSON: Finally it was good to hear the Commissioner say that as far as the Department's actions go, he is responsible.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: Forget all the committees, at the end of the day I am the person that is responsible for the Department and the actions of the Department, and I take that responsibility.

Alright, thank you.

LIZ JACKSON (to Ian Johnson): Look you are saying you accept responsibility for what happened, are you saying that you accept responsibility for the fact that the Department was on notice that it was an inhumane and dangerous system that was in place in relation to prisoner transport are you accepting responsibility for that?

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: What I said there to the people here today is that I'm saying sorry, and secondly he asked who was responsible for the Department, that's me.

LIZ JACKSON: So, do you accept that.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: No, please let me answer, what I said to him was that I'm sorry, and secondly when he said who's responsible for the Department, I said that's me, that's what I said.

LIZ JACKSON: Does that mean you are responsible for the fact.

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: No, I'm here to actually speak to the family members.

LIZ JACKSON: That the Department has been on notice for a number of years that it's an unsafe and inhumane system, do you accept that an inadequate response was made to those reports and recommendations?

IAN JOHNSON, COMMISSIONER FOR DEPARTMENT OF CORRECTIVE SERVICES: What I came here today for was to say sorry to the family, not to have a media event, to say sorry to the family, and when asked a question about who's responsible for the Department, that's me. That's all I have to say, that's all I have to say.

(End of Excerpt)

LIZ JACKSON (to Margaret Quirk): Do you feel you can say to the Ward family that the state did exercise a duty of care in relation to Mr Ward?

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: No I think we were negligent and I myself regard myself as personally responsible even if I'm not legally responsible.

LIZ JACKSON: Have you met with the family?

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: No I ah, I ah was waiting til after the Coroner's inquest and ah I certainly had messages passed onto them on my behalf but no I haven't.

LIZ JACKSON: Are those messages saying sorry?

MARGARET QUIRK, WA CORRECTIVE SERVICES MINISTER 2006-08: Of course they're saying sorry. (Wipes a tear from her cheek)

DENNIS EGGINGTON, WA ABORIGINAL LEGAL SERVICE: I'm sure that she was upset. But in the end where does the buck stop? It's got to stop somewhere.

LIZ JACKSON: Three days ago the West Australian Coroner handed down his findings in relation to the death of this man, Mr Ward.

The findings were damning.

The Coroner found that Nina Stokoe and Graham Powell, the Department of Corrective Services and the company GSL had all breached their duty of care, and each had contributed to Mr Ward's death.

The Coroner indicated he believed a criminal offence may been committed, and would refer this to the DPP (Department of Public Prosecutions).

Finally, he put this question, how could a society which would like to think of itself as civilised allow a human being to be transported in the way that this man was.

[End of transcript]