Mark Holcroft — a sentence of repentance and death

Mark Holcroft was born in the same year as I, 1950

Mark died in the back of a prison van
They rode him in custody down from Bathurst
Mark who had 59 years, personable nature
came from a close and supportive family
The journey from Bathurst to the farm site at Tumbarumba
Was one of  five hours duration
Minimum gaol for minimum inmate
But his crime was being drunk
Punishment not restricted to loss of liberty
The magistrate handed down strongly
a sentence of repentance
through Cowra, Cootamundra, Batlow,
and Tumbarumba
Which led to his death in a prison van
No response from the driver
heard yelling in the back of the van like he’d never heard before

in the vicinity of Batlow
Insecure location didn’t think anything was wrong

Mark collapsed in the prison van
and became unconscious
Innmates  yelling, screaming, men crying.
 terrible situation to be in
The noise being made by the inmates in the van
Not attracting the attention of the guard
a scene of chaos
Only prisoner Afif  saw something different
to what others saw

On arrival the noise of the innmates
finally awoke the guards from their boredom
who directed that the van be opened
Efforts of the Justice Health staff
and ambulance officers were not able to assist
subsequently pronounced Mark’s life extinct

Oh, but you who philosophize disgrace and criticize all fears,
Bury the rag deep in your face.
For now’s the time for your tears.

(quotes from Lateline, Coroner’s Report and Bob Dylan in ‘Lonesome Death of poor Hattie Carroll)
poem by Ian Curr

Mark's family

The journey from Bathurst CC to Mannus CC was one of approximately five hours duration. To get to Mannus from Bathurst it is necessary to travel through the New South Wales towns of Cowra, Cootamundra, Batlow, andTumbarumba. It is a distance of a little under 400 kilometres.—MS Holcroft Coroners Report


  1. Ray Jackson’s Report
  2. ABC report – death of mark holcroft who died of a heart attack whilst being transported from bathurst gaol to the farm at tumbarumba on 27 august 2009.
  3. Prison van inmates’ cries for help ignored. Australian Broadcasting Corporation Broadcast: 20/07/2011 – Reporter: Steve Cannane
  4. MS Holcroft Coroners Report.pdf

Somewhere in the vicinity of Batlow Mark collapsed in the prison van and became unconscious. Other inmates tried to attract the attention of the drivers of the vehicle and laid him on the seat in the section of the van in which he was travelling. The van continued onto the Mannus CC arriving at about 1.40 pm.MS Holcroft Coroners Report

Ray Jackson Report
on 22 july i posted my views relative to the inquest of mark holcroft who died as a result of a heart attack whilst being transported by corrective services from bathurst gaol to the farm site at tumbarumba that is used as a minimum gaol for minimum inmates.

On arrival at Mannus CC the noise being made by the inmates attracted the attention of DSC officers who directed that the van be opened.
The inmates were removed and Justice Health staff attended to Mark. NSW Ambulance officers were also called and on their arrival they took over from the Justice Health staff. The efforts of the Justice Health staff and ambulance officers were not able to assist Mark and he was subsequently pronounced life extinct.— MS Holcroft Coroners Report

i have no wish to re-invent the wheel or my opinions at that time. a rereading shows my words to be still relevant so i reproduce it again below.

attached is the 29 page findings and recommendations of the inquest conducted by deputy state coroner macmahon that he handed down on 12 august 2011. i will restrict my comments now to his decision.

before i do i congratulate the holcroft family in electing barrister, ms. ragni mathur to represent them. i know ragni from her time at the redfern aboriginal legal service where her skills were early identified and appreciated. ragni is well known as a barrister who fights for those she represents. i am sure that the good points that were picked up by macmahon were as a result of her arguments to him. well done ragni.

on page 2 of his decision the deputy state coroner begins his recommendations and i will start there also.

the first of his recommendations deals with the supply to inmates being transported. he describes the lack of food, water and comfort stops as a “privation,” which of course it is. this “privation” however has been recognised for many, many years dating back to the early 90’s when the watch committee raised it regularly as being an abomination. on short trips of no more than 2 hours the “privation” is minimal. for trips of a longer duration we argued the same facts but to no avail. some trips can take up to 8 or more hours and inmates are not even considered during these longer trips. we are told that corrective services now supplies food and bottled (plastic) water to inmates. and not before time.

the 2nd and 3rd can be addressed by technology. i am surprised that the transport officers have not addressed this problem for themselves, especially with their well known predilection for their own safety.

rec.4 is also a concern that has been raised with the transport heads for over 20 years. many things other than heart attacks happen whilst inmates are being transported. there has been inmate on inmate assaults, including the use of gaol-made knives. whilst staff attempts to make sure that inmates having problems with other inmates is known, it doesn’t always work so it is absolutely necessary that a working two-way communication device is always available. rec. 5 is a continuation of this need. both devices must be recordable and kept for 2 weeks, as macmahon has stated.

rec. 6 is also, and must be, a given. no gaol transport that has faulty communication devices, faulty air conditioning or other important items not operating correctly, cannot and must not be used. any operational problems that this could cause must be accepted and other safe transport found.

rec. 7 is a strange one. s.13.2 of the gaol policy and procedures manual, the gaol officers bible, was removed in 2010 for some unknown and unstated reason. the normal procedure, however, for a death in a gaol is that the wing/pod where the inmate has died is locked down whilst other wings/pods have restricted access. the cell where the death occurred is locked and a comprehensive process involving gaol officers, including the general manager or governor, local police, etc., etc. is played out. in my 20-odd years working within the gaol system i never read any direction on a death in custody whilst being transported. i believe that the same procedure used for mark holcroft would be the norm.

the call for disciplinary action against gaol officers is not new. in other death in custody cases, coroners have made such recommendations, at least since the early 90’s but it is never made public, or to the families involved, as to whether such disciplinary action is taken. the major problem with this procedure is that justice, such as it is, is not seen to be done. there is, therefore, no closure possible by these families already suffering the loss of their loved one(s). recently i was approached by the partner of a young man who died at the old long bay remand gaol in june, 1994. that death in custody was caused by the negligence of the wing officers who failed to check that the cells were empty when the inmates were sent to the yard. the coroner made a recommendation that the two officers be dealt with but to this day it is still not known if they have been. like the police, this information is just not known. for the benefit of the families i believe it must be made public or at least made to those families.

the two recommendations for justice health attempt to cover-up a multitude of problems. problems that do cause deaths in custody because of some medical staff not doing their job properly. why the police, gaol officers and staff and custodial health operatives are allowed to continue to use the same tired and worn-out excuse that they do not know their duties properly and therefore cannot be given blame for these discrepancies is beyond me. every worker has their own list of duties that they must know and must follow. do the different departments need to retrain all of their employees? it seems so. all custodial employees have a duty of care to those in their care and they must be fully aware of their requirements to their charges.

pages 4/5 para 6/7 show that the transport officers state that when mark collapsed they were in or just leaving batlow. having been to batlow i can state that batlow has good hospital facilities and a working police station. why did not the transport officers utilise both to check on the health concerns of mark? simple answer, they could not be bothered. it’s as simple as that.

page 6 para 14/15. whilst accepting that mark died as the result of a heart attack the coroner goes on to state “that mark died of a natural cause process.” what!!!!! what is natural about a death that is brought about by the negligence of justice health and callousness by the transport officers? activists within and without of the custodial systems must not allow this ridiculous term to have any currency. the greater majority of deaths in custody always have pertinent and possibly criminal underlying causes brought about by a complete lack of duty of care. i and others will always argue that custodial deaths are as far removed from natural causes as is the death penalty.

pages 7/8 para 20/21. dr raftos, an associate professor, believed that mark had a 10 minute window for medical treatment to occur. whether that window would have been met by attendance to the batlow hospital will never be known but it should at least been attempted. for all the reasons i have given in my previous post, this was doable. both transport officers ignored the tumult from the cages in the van and just drove on. normal practice.

pages 9/16 para 23/56. coroner macmahon looked closely at the assistance and treatment given to mark by justice health personnel and found it to be lacking in quality. the banner that justice health is most proud of is that their medical procedures to inmates is equal to, or better, than that available to the public. for simple medical attention, such as headaches, scrapes and scratches, etc., this may be true but for those complaints requiring the input of a doctor the wish statement falls down. complaints against justice health are legion and they mostly have veracity to them. sometimes it can take weeks to see a doctor to be assessed for outside medical treatment which may also add further weeks to the process. nurse pointer at the metropolitan reception and remand gaol (mrrc) saw mark re his complaint of chest pains. she gave him some anginine along with that well known cure-all, aspirin. she also arranged for an onsite ecg and referred him to dr. badami ( a gp) for further consultation at the gaol clinic.

dr badami sought a second ecg for mark and subsequently misread both of them. this fundamental error cost mark his life. the dr. decided that mark was merely suffering from reflux and mark was to be reviewed the following week. dr. raftos was scathing of the findings of the two ecg’s and opined that mark should have been sent straight to a hospital for better care. tragically dr. badami put him back to his cell awaiting transportation. whilst he did concede his error i find it difficult that a competent doctor would have made the same error. it has been stated over the years that justice health does not always get the best doctors to work within their system. mainly due to low recompense, among other things. it is well known that justice health, like the gaol system, is grossly underfunded and this has caused the individual gaols attempting to pass the medical costs on to other gaols, even to the issuing of medications prior to transport. all the inmates stated that mark and another requested medication at bathurst but this was denied by the nursing staff. nurse douglas at bathurst gaol stated that she had asked if anyone needed medication but received no reply so none was issued. experience leads me to accept the inmate statements as being the facts of the situation. macmahon decided to leave this matter open, i.e. he could not find where the truth lay.

pages 16/21 para 57/76. a close analysis of the events involving the transport officers and the inmates upon the collapse of mark led him to the only conclusion that he could find. both officers of course told the same story but peter sheppard was found to be unreliable as to his evidence of what he heard and saw whilst driving from batlow to tumbarumba. his demeanour during the inquest was described as arrogant and uncaring of his actions. macmahon has recommended that he be disciplined by corrective services. please, do not hold your breath waiting for this to happen. the povb, their union, will make sure of that. this situation would be an ideal one for a citizens board, if one existed, to monitor what disciplinary action was given and to view its adequacy. we need such boards to ably monitor our custodial systems as they have in america.

pages 21/29 para 77/110. other matters are now raised for consideration such as the failure of corrective services to supply food and water, the failure to provide comfort stops, the failures of dr. badami and whether he should be reviewed by his peer body, and other recommendations from the family and the barristers involved.

i have made comments already on the food, water and comfort stops so i will not address them but the actions and non-actions of dr. badami need to be revisited. page 24 para 87/89 shows quite clearly that along with the deadly errors made by dr. badami, he also made other dangerous omissions. dr. badami failed to note in the computer generated patient assessment system that mark had an appointment “next week.” such a notation could have been accessed by nursing staff advising them of that fact. but it was not there. in my opinion i would advise justice health to either make dr. badami do a full retraining and analysis of his responsibilities or, failing that, terminate him and refer the matter to the medical review board. justice health must recognise that whilst they believe their service to the inmates is worthy of applause if they keep incompetent doctors or nurses within their clinics then inmates have little to no choice as to who they see for treatment. this is merely a recipe for further deaths in custody. the doctor was let off the hook by macmahon. shame.

page 27 para 100/102. witnesses to any event must be kept separate to allow honest statements to be made but this practice must also include all custodial officers. as we know this is rarely done and some coroners merely shrug their shoulders. all evidence in a court of law where it can be shown that collusion between officers has occurred should be immediately struck out. the systems are notoriously collusive as we know and such collusion must be stopped.

page 29 para 110. the family requested of the deputy coroner that transport vehicles be fitted with defibrillators and training be given to the transport officers in there use. i have little faith in this request and if defibrillators were to be installed then a nurse would need to travel on every transport. this is just not possible due to cost but transport officers must be instructed to go to the nearest hospital for medical treatment. police can meet the van at the hospital and the medical inmate be extracted, safely, for proper and humane treatment. they must do as they would do if one of their own collapsed. all life is precious, whether officer or inmate, and inmates are not in gaol to die because of callous treatment by custodial officers.

all in all, i think that corrective services got some shake-up but the coroner should revisit in 12 months to review their proper implementation and practicality. justice health got off too easy and more serious recommendations must be made to bring justice health up to the mark that they have set themselves. way too many deaths in custody in gaol and police cells are now health related and this trend must be stopped. these deaths are not by natural causes. the death of mark holcroft clearly shows that to be the case.


ray jackson
indigenous social justice association

22 july 2011
herewith another report from steve cannane of lateline who also did the original death in custody report (6/3/10) on the death of mark holcroft who died of a heart attack whilst being transported from bathurst gaol to the farm at tumbarumba on 27 august 2009.

the inquest into his death began at wagga on 18 – 22 july this year and will continue at the glebe coroners court from 25 – 29 july should anyone wish to attend.

steve’s report raises several areas of great concern that we can only hope that the coroner will already be aware of.

the first of those concerns is the information given that the transport vehicle was used even though it proved to have several faults with it. this situation has alarming echoes of the death of mr. ward in wa whereby he was transported in a faulty vehicle, no air-conditioning in the transport cell, and as a horrifying consequence of that, mr. ward was literally ‘cooked’ to death.

mark holcroft died of a heart attack in the transport van even though the van was driven past two hospitals at least on their way to tumbarumba. the puerile excuses made by the two drivers is ridiculous but is normally accepted by police investigators who generally attempt to push the onus of death away from the drivers to the faulty transport vans as being the sole cause of the death.

the actual quoted statements from transport drivers bateman and sheppard are not surprising. bateman believed that all the noise only occurred because the inmates ‘were bored. of course they’d be bored on a 4 hour journey with nothing to do but sit there without food or water or any opportunity to relieve themselves. 4 hours locked up in a cage with 6 other inmates can be one hell of a trip. the vans can carry up to 24 with three large cages and two single cages for protection prisoners or females as required. it gets very noisy but those inmates attempting to raise the attention to the problems with mark would have been a more focused and dedicated noise. bateman did agree that the noise from the cages this time was somehow ‘different’.

so too sheppard should have been aware. in fact he would have been more aware as he states that he was monitoring the inmates on the cctv but saw nothing unusual. inmate statements tell of a situation of utter chaos in the cage that mark had collapsed in and they further described laying mark out on the bench forcing those inmates in that cage to stand. how this could not be seen by sheppard is beyond comprehension and truthfulness.

as an official visitor for 10 years i received complaints from inmates of the absolute bastardry of some, and i stress only some, drivers who would feed cold air to the cages in winter or hot air in summer. i always put it down to the drivers being bored and in full control of the environment in the cages. i argued for some six months for official visitors to go for a short trip in the transport vans so as to example for themselves what it was like. this did eventually occur but it had to be called off when one of the official visitors passed out but at least it gave them a taste.

i missed out on that example so i had to push for my own individual trip which finally happened when the boss of the transport, allan chisolm at that time, set it up for me. i had no wish to sit in the single cage because of space considerations so had a large cage appointed to me. we drove around for ten or fifteen minutes and i must have had an non-bored driver who fiddled not with the environment of the cages. i certainly had a better understanding of what the problems of journeys of 4 hours or more would be.

the inmates being transported on the long journeys are locked up from gaol to gaol. there are no comfort stops either. during stops along the way, so the drivers can eat or toilet themselves, the inmates remain caged. when a transport van breaks down they remain caged until the repairs are done or a new van brought in. they are not fed or watered until they arrive at their new gaol regardless of the time of arrival. the security of the van is you have a lockable outer door whilst inside each individual cage is padlocked. drivers may open the outer door without coming into physical contact with the caged inmates. bateman and/or sheppard could have stopped, opened the outer door without their safety being compromised and ascertained what all the yelling was about. they chose not to and just kept driving.

bateman is then quoted as making two opposing statements. the first was that the van was in a ‘insecure location’ and that he understood the inmates rowdiness was an outcome of boredom. either he was aware of problems in the cages but considered themselves to be in an insecure location and so was not in a position to assist or he accepted the choice that the inmates were bored. whatever the circumstances in the van cages drivers are told not to stop unless they are at secure locations. these secure locations are a police station or another gaol and under no circumstances do the drivers deviate from that call. their own individual safety is paramount and their duty of care to the inmates come a far distant second.

the inmates in their statements referred to the drivers driving past at least two hospitals after mark had collapsed. i would argue where there are hospitals there would also be police stations. why then did not the drivers utilise these secure locations? we also must remember that the inmates were all minimum security and going to a farm rather than a gaol. they most definitely were not flight risks under any circumstances i would argue.

sheppard’s reply to the question why the large discrepancy between his evidence of what he saw, virtually nothing, and the testimonials of the inmates is beyond belief. what he is implying is that his version of events is true whilst that of the inmates is a fabrication emanating from mob hysteria. again this practice is not uncommon and is widespread throughout the custodial systems. we must never forget that over the near two years between event and the coroners court they would have been well advised by the corrective service legal teams as to what to say. same as in the police jurisdiction. sometimes however their own arrogance trips them up from time to time.

we are then left with the most important question, perhaps, of all. like the g4s transport for mr. ward, why did the transport division of corrective services allow these inmates to be transported in a faulty van? only one of three cameras worked thus hindering, apparently, sheppard not being able to see in full the frantic attempts to inform the drivers of the tragic events happening in the cages. the failure of the intercom also led to this event being exacerbated. the coroner must order the transport vans and cars to be fitted with emergency or knock-up buttons in every vehicle. for the complete safety of the inmates there must be audio devices fitted that will allow the inmates to have voice contact with the drivers. drivers should not be able to tune this device out or be switched off.

duty of care is relative to all, from inmates to drivers and officers and from officers and drivers to the inmates.

i find it hard to believe that bateman and sheppard were in ignorance of the tragic events in the transport cages but they both elected to not extend their run by stopping and merely wished to pass their responsibility onto to the mannus personnel. they totally and knowingly abrogated their duty of care and must be found to be culpable in the death of mark holcroft.

i wish to raise here another matter that concerns me greatly and that is the shut-down of the last family support unit for inmates and families during december last year. this was shut-down by the ceo of the redfern aboriginal legal service, gerry moore, in a unilateral action i believe. it seems he could see no further benefit in continuing with this unit and he apparently has other plans for the funding of that unit. i understand that that leaves nsw with no real ability to assist families during death in custody happenings. except on a legal basis.

more on this at a later date.


ray jackson
indigenous social justice association

Prison van inmates’ cries for help ignored

Australian Broadcasting Corporation

Broadcast: 20/07/2011

Reporter: Steve Cannane

The driver of a NSW prison van in which an inmate died has told an inquest he thought the noise of inmates calling for help was because they were ‘getting bored’.


TONY JONES, PRESENTER: The driver of a NSW prison van in which an inmate died has told a coronial inquest he heard noise in the prison van like he’d never heard before, but he didn’t consider pulling over to find out what was going on.

Clive Bateman gave evidence today at the coronial inquest into Mark Holcroft’s death in 2009.

He said he assumed the banging and noise coming out of the van was because the inmates were getting bored.

The other driver of the prison van, Peter Sheppard, says he was monitoring vision coming from cameras in the back of the van and he said everyone seemed to be sitting up normally.

Steve Cannane reports from Wagga Wagga.

STEVE CANNANE, REPORTER: 59-year-old Mark Holcroft died of a suspected heart attack in the back of a prison van in August 2009. A low-security prisoner, he was being transported on a four and a half-hour journey from Bathurst Gaol to a prison farm near Tumbarumba.

Last year, four inmates who witnessed his death spoke to Lateline about how they tried to alert the drivers that Mark Holcroft was having a heart attack. These interviews were tendered as evidence at the inquest.

INMATE: We were all banging and screaming, trying to let the drivers know, pull over, you know, the guys – something wrong with him.

INMATE II (March, 2010):We were banging all the way for 40, 50 minutes, all the way to Mannus. Every town we stopped at, we thought someone could be able to hear us. We were yelling, screaming, men were crying. It was just a terrible situation to be in.

STEVE CANNANE: Today the inquest heard for the first time from the drivers of that prison van. Clive Bateman told the court that he heard yelling in the back of the van like he’d never heard before. When asked why he didn’t pull the van over, Mr Bateman replied, “Insecure location. … I didn’t think anything was wrong.”

Mr Bateman also told the court he thought the noise was related to boredom. “I made an assumption the men were getting bored.”

While Clive Bateman was driving, Peter Shephard was in the passenger seat monitoring inmates via cameras. Mr Shepherd told the court, “There was nothing obvious that was showing up there was any trouble.”

When asked why his evidence conflicted with the inmates, who described a scene of chaos, he replied, “I just saw something different to what they saw.”

Last year, Afif Khowly told Lateline he’d trying signalling to the cameras.

AFIF KHOWLY, INMATE (March, 2010): I remember I was putting signing and putting hand sign to the cameras because this truck had four cameras, one in each corner and in just pointing out when that person is laying down.

STEVE CANNANE: But the court heard today only one camera in each compartment was working. Afif Khowly might have been motioning to a camera that didn’t work.

The inquest also heard the PA system that allows the drivers to communicate with the inmates was not operational.

PETER DODD, PUBLIC INTEREST ADVOCACY CENTRE SOLITICOR: There was a facility for the drivers of the van to talk to the people in the back of the van, but that wasn’t working. That wasn’t functional. And there’s no communication provided for the prisoners in the back of the van to talk to the front of the van.

STEVE CANNANE: Next week the coronial inquest moves to Sydney and begins hearing evidence about the medical treatment Mark Holcroft received inside the prison system in the days leading up to his death.

Steve Cannane, Lateline.

ray jackson
indigenous social justice association

MS Holcroft Coroners Report.pdf

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