'A great tragedy': Push for action on drugs, lack of activities in AMC

Coroner Robert Cook on Wednesday handed down his findings and recommendations of the inquest into Mr Freeman's death in the Alexander Maconochie Centre in May 2016, as a result of aspiration pneumonia secondary to methadone toxicity.

His report made seven recommendations to improve the prison's screening processes for drugs, its opioid treatment program and that the government consider daily physical education sessions for inmates, among others.

Corrections minister Shane Rattenbury said Mr Freeman should never have died in the government's custody and that it was a great tragedy he did.

Mr Freeman's death and the independent investigation into it by Philip Moss, brought into sharp relief a number of longstanding problems in the AMC since it was opened, including the lack of structured daily activities, the availability of drugs and the ease with which inmates accessed the methadone program.

Mr Rattenbury said while the government had already implemented some of the coroner's recommendations it was working on addressing the remaining ones.

While he said the government would formally response to the coroner's recommendations, he would go further to help improve the lot of detainees and help them to rehabilitate.

"My overall position is we have made a series of changes since Mr Freeman's death and I will now look closely at the findings to see what further things we need to do," he said.

"There have been changes at AMC, both in response to Steven's death, but also a general quality improvement process - there are areas I want to continue to change at the AMC."

The coroner also recommended the government consider updating its opioid treatment guidelines to meet national standards, which it has done, since it was reported those guidelines were three years out of date when Mr Freeman died.

Mr Rattenbury said the government had made several changes already to that program in the prison, including an electronic dosing system.

But despite community concerns the out-of-date policy may have contributed to Mr Freeman's, the Coroner stopped short of such a finding and Mr Rattenbury said it could not be certain whether "such specific measures would have changed the outcome".

Mr Rattenbury and his acting opposite number, Canberra Liberals' Andrew Wall, both agreed on that key to improving the prison were addressing the supply of drugs inside and the lack of a structured program of daily activities.

Mr Wall said it was clear the government had made mistakes and that prison staff either did not adhere to procedures and policies, or the government had not kept such measures up to date.

He said the government needed to address those issues as a matter of urgency to ensure no other lives were lost.

"I think personally the nub of the issue is drugs in the prison, and so long as there are drugs in the prison and practices of drugs being used as currency we're going to keep seeing these issues,' Mr Wall said.

"If we can address the drug problem, we can start to address the other issues."

But Mr Wall also said the lack of a structured day for inmates was "a big cause for concern" and that custodial sentences created an opportunity for people to be rehabilitated and give them skills to become a "contributing member of the community" on release.

Mr Rattenbury said he was also working on giving inmates more chance to participate in such activities-  including the recent opening of a bakery at the AMC - but that many inmates did not want to "sit around studying" and the government needed to provide more "hands-on" activities.

While Mr Wall supported the government actively making changes and initiating the Moss review before the coronial inquest was completed, he said making such changes after a death but before the inquiry was "kind of government admitting there were problems all along".