The treatment of Indigenous inmate Steven Freeman has highlighted wide-ranging failures of the ACT's justice system, an independent inquiry has found.
Mr Freeman died at the prison in May, although the cause of his death remains unclear and is the subject of a pending coronial inquest.
But a separate inquiry, conducted independently by former integrity commissioner Philip Moss, has now found that the broader treatment of Mr Freeman was deficient, marred by a series of failings involving corrections, police, and health authorities.
Mr Freeman had been near-fatally bashed inside his cell roughly a year before his death.
The bashing took place within hours of Mr Freeman's arrival at the jail, and after the remandee was lumped with sentenced prisoners – a practice that has become common, despite it being against a core tenet of human rights-compliant facilities.
Mr Moss' report - handed to government on Monday and released on Thursday - found that Mr Freeman would likely never have been assaulted if he had been initially placed in a separate unit designed to hold new detainees for up to five days, while more thought-out decisions were made about their placement.
That unit now exists at the prison.
The police investigation into the bashing was deficient. Police did not ask for, nor were they given, a record showing access to Mr Freeman's cell in the 10 minutes before his assault.
Had they done so, they would have seen that a swipe card opened the cell door three times between 6.15pm and 6.33pm, the inquiry found. Mr Freeman was found seriously injured at 6.30pm.
The medical treatment of Mr Freeman left much to be desired.
He underwent a range of welfare and health checks when he returned to the AMC on May 7, after the bashing, but was not seen again personally by a justice health services officer after May 20.
The inquiry found the follow-up of Mr Freeman's head injury by the jail's health team ceased altogether in September.
The AMC did not assess his cognitive functioning after the bashing, despite fears he may have sustained permanent brain injury.
"Discovering whether there was any long term impact of the head injury and trauma Steven Freeman suffered while in custody at the AMC does not appear to have featured prominently in [his] ongoing management," Mr Moss wrote.
He was placed on the methadone program, despite his family claiming he was not a heroin user.
Another inmate told Mr Moss:
"You only have to say you got a drug problem … and you want to get on that [methadone] and they'll chuck you on it."
The inquiry also found Mr Freeman complained of a tooth pain so severe he was unable to eat or sleep on January 1.
But the delay in him seeing a dentist was so great that he still had not received treatment by the time of his death in May.
Mr Moss also found the mental health care and counselling of Mr Freeman was inadequate. He noted that tensions between ACT Health and ACT Corrective Services, revealed by Fairfax Media in August, still exist in the jail, a finding that conflicts with previous assurances of the ACT government.
Mr Moss found Mr Freeman spent 395 days at the prison, all but 52 of which were on remand.
No case plan for his rehabilitation was developed during that time.
He was bored, had little to occupy him, and lacked a structured day. He spent far less than the recommended 30 hours a week in activities or programs.
Other inmates told Mr Moss the actual time detainees spent in programs was more like one to two hours a week.
"The Inquiry notes that the lack of a structured day inevitably leads to boredom, which invites the possibility and added risk of detainees using illegal drugs," Mr Moss wrote.
The inquiry has recommended restoring separation between remand and sentenced prisoners, and improving information sharing between health and justice authorities.
Mr Moss found there was a need to reform the relationship between justice and health teams operating at the jail, and introduce the Winnunga Nimmityjah Aboriginal Health Service. He called for a review of CCTV surveillance at the prison, looking at the expansion of cameras and better training for prison officers.
Those who bashed Mr Freeman were not captured on CCTV.
Police and prosecutors should adopt a pro-charge and pro-prosecution approach to prison bashings, Mr Moss said, while methadone prescription at the jail should be examined by the Health Services Commissioner.
Legal Aid deputy chief executive officer Louise Taylor issued a statement on behalf of Narelle King, Mr Freeman's mother.
Ms Taylor said Ms King welcomed the report as "one further step along the road to seeking justice for her son".
"The Moss Inquiry Report reveals, at least to Narelle King and her family, that the care afforded to Steven Freeman in custody was deficient," she said.
"The Moss Inquiry Report raises a number of crucial questions about the investigation into the assault on Steven Freeman in custody – those questions still need answering."
"Steven Freeman should still be alive. He was a loving son, a loyal brother, a committed partner and a proud father – those who loved him miss him every day."
Corrections Minister Shane Rattenbury said he would consider the report and its findings. He said he broadly supported the recommendations, but would give a formal response in the new year, after the coronial inquest, which begins on December 5.
Mr Rattenbury said the report had identified "shortcomings and areas where improvements must be made".
"The government will act on these findings because we cannot ignore what has happened to Mr Freeman," he said.
"The report does identify a deep sense of grief in the Aboriginal and Torres Strait Islander community about the passing of Mr Freeman, I think more broadly it also identifies a grief around the number of Aboriginal and Torres Strait Islander people that are in our jail. We have too many.
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