Aboriginal and Torres Strait Islander readers are advised that this report contains content about a person who has died.

Mr Morrison was remanded in custody on 19 September 2016 in relation to a number of criminal charges. Mr Morrison died following an incident at Yatala Labour Prison which occurred on 23 September 2016. This report includes a number of serious criticisms of the Department of Correctional Services.

Key Findings/Recommendations:

• The Department of Correctional Services failed to raise a ‘notification of concern’ and treat Mr Morrison as an ‘at risk’ prisoner, despite his past attempted suicide and family history of suicide, and failed to have proper processes in place to identify Mr Morrison as an Aboriginal person (and to provide support accordingly). The Department needs to develop a warning system whereby a prisoner’s history of actual (and threatened) self-harm and suicide attempts is electronically flagged at all times.
• Mr. Morrison was transported in a van without video recording capacity and there was failure to record meaningful footage of Mr Morrison’s restraint by Correctional Officers. The Ombudsman recommends that the State Government take steps to implement body-worn cameras within all of its prisons.
• There were serious shortcomings in the department’s dealings with Mr Morrison’s family, and that the situation could have been better handled.There was failure to provide Mr Morrison’s family with sufficient information, support, and access to Mr Morrison while he was in hospital. It is a requirement that all relevant clearances are provided as soon as possible after a prisoner is evaluated as having a life-threatening condition or is unconscious and that next of kin are advised of all requirements for access to the prisoner.  
• The Department needs to develop a procedure for dealings with next-of-kin of prisoners who are critically injured or who die in custody, including the identification of a single point of contact and chain of command for enquiries and information for families and provision of counsellors, social workers, chaplains and other support as appropriate.