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(generated from captions) everything. He would like to

pull back a touch over the next 12 months at least. That is

what he's saying. I don't know

whether that will happen. I

know him well enough to know that that probably won't know him well enough to know

happen, but his face is now

going to be shown publicly so

that will mean it would be a

good idea if he took a lower

profile. In a way Thailand

saved me. Through helping other

people it redeemed me as well,

if that makes any sense. What I found is that found is that living for

yourself only gets you so far.

But once you start living for

other people as well, it makes

a big difference in your happiness in life.

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This Program is Captioned Live. Good evening. Virginia with an ABC news update. Peter Good evening. Virginia Haussegger guessing game over his Costello has ended a 19-month future, and with it, any guessing game over his political politics at the next election leadership ambitions. He'll quit what he calls the politics at the next election after what he calls the 20 best years of his life. Kevin Rudd and Malcolm Turnbull Turnbull were quick to praise the former treasurer. Another member of the notorious Moran family was shot dead in the

Melbourne's gangland war. Desmond dead in the latest chapter of 'Tuppence' Moran was ambushed by two

gunmen inside his favourite city cafe. He is the fourth member gunmen inside his favourite inner

the Moran family to city cafe. He is the fourth member o Israel's Prime Minister has agreed the Moran family to be gunned down.

support Palestinian statehood but Israel's Prime Minister has agreed t

Benjamin Netanyahu independent Palestine can only Benjamin Netanyahu says an if it has no army and it recognises independent Palestine can only exist Israel as a Jewish state. New Wales has made five changes to its Israel as a Jewish state. New South side for game two of the State Origin series against Queensland. side for game two of the State of Paul Gallen, Glenn Stewart, Anthony Watmough , David Williams and Barrett come into the side. Watmough , David Williams and Trent

Campese and Anthony Laffranchi Barrett come into the side. Terry been dropped. And Campese and Anthony Laffranchi have - early fog then mostly sunny, been dropped. And Canberra's weather 13 degrees. Sydney - - early fog then mostly sunny, 2 to 15. Adelaide - 17. More news in 13 degrees. Sydney - 17. Melbourne -

hour. 15. Adelaide - 17. More news in an


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. under the influence of alcohol. He was arrested for driving The following morning he was put here, in this van, by a private security firm to be carted to Kalgoorlie gaol of the day. 400km through the blazing heat

42 degrees, Outside the temperature reached steadily increased to over 56. inside the surface of this metal cell in custody was dead. By mid-afternoon, the Aboriginal man a slow and shocking death. Mr Ward had died

such horror My goodness sake, one can only feel at slowly being cooked. It's the unspeakable. It's the unimaginable to me. to happen It's a death that didn't need that shouldn't have happened. and it's a death

Why did they do that to my cousin? Tonight onFour Corners - Who killed Mr Ward?

three weeks ago. The township of Kalgoorlie, inquest into Mr Ward's death, It's the last days of the coronial held at the Kalgoorlie Courthouse. have travelled in His family members north-eastern communities from the remote Patjarr and Warakurna, of Warburton, Tjuntjuntjara,

between 500km and 1,000km away. His widow, Nancy, and their children, his sisters and brothers his cousins and friends, and his mother. from the Ngaanyatjarra lands. They're desert people As part of custom they've requested not be used. that Mr Ward's first name ABORIGINAL SINGING in the Western Desert. Mr Ward was himself born His family, seen here, their traditional way of life. was amongst the very last to leave This film was made in 1965. His father was Tjakamarra. Marundinjiyara linguistic group VOICEOVER: Tjakamarra of the is camped at Baddya of the Western Desert and seven children. with three of his four wives of the seven children, One of the youngest carried by his sister Dunera. Mr Ward is seen being He's aged around three. One of the elder girls,Dunera, with her young brother on her back,

and off they set. picks up a firestick This is his mother, Katapi. Katapi starts gathering the seed.

The whole seed head is pulled off. Mannubaand her daughter watch the others working.

to help her balance herbiddy'. Katapi has a circle of emu feathers is on his mother's lap. Mr Ward, called Nampukutji, from Katapi's breast as she works. Nampukutji sucks The same year this footage was shot, the family moved from the desert, in the remote community of Warburton. to the more Westernised life Four decades later, community chairman, the suckling toddler was Warburton's of 9 million hectares and employed in the management of the Ngaanyatjarra Lands. And we are the decision-makers with the government. who are working the minister for coming... We would like to thank

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

of the English language He had a very good grasp from, anyone from, you know, and could communicate with people the ministers, federal ministers, through to mining companies, to ask questions people who just wanted of the Aboriginal people about the different history out in the Ngaanyatjarra Lands. as a friend? And someone you regarded definitely a friend. Definitely, yeah, of his lifetime, So, really, in the space traditional sort of way of living, he had gone from a completely to being able to go to China

on land management and represent his people in China to politicians or to talk in Parliament House

and he was very proud of it, so he called himself the last of the Stone Age men. The community of Warburton and the surrounding lands are dry. The nearest legal drink is a 600km drive down here to Laverton, and having gone that far, many people have more than one. LOUD MUSIC AND SHOUTING

Saturday nights are busy nights for the Laverton police, especially in the summer months, the holiday period. POLICE OFFICER: Hey, you alright? This period late December, January, is a time when people do go to Laverton and they do get very drunk. If you are a drinker and often it's binge drinking.

On the Australia day weekend, 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.

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, ah, sorry. He didn't drive too much, and drove. And that's typical of many people in Sydney, Melbourne, Brisbane, Perth, everywhere. What's not so typical in Sydney, Melbourne, Brisbane and Perth are the events that followed. 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 Barry Thompson told us he knew nothing about this. I certainly wasn't aware of that, that there'd been a pre-booking. Ha, ha. I certainly wasn't. Um, and the first I knew... But you... The first I knew was a phone call at 9 o'clock in the morning. What would you have thought

about the fact that there'd been a pre-booking? Um, I would've been a little disappointed. Because what does that indicate to you? Well, that, you know, that they've made a pre-arrangement and sort of, ah... ..and to me what was going to happen depended on my decision on the assessment of the cases. 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 10 minutes. Is that a properly constituted bail hearing? Um... Is that fair?

Well, put it this way, I presumed it was.

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 he wasn't a violent person. No, this person wasn't violent, no, I must admit. And he was asleep when you arrived. Yes. And he was woken up and it was a 10 minute hearing.

Yes, yes. Is that the way you'd like your bail to be considered, to be woken up and have a 10-minute hearing? Um, it's not unusual. I mean if... But is it fair? Fair to whom? To the prisoner? The prisoner? What, so you should think that the - he should wait ah, wait until about 12 noon until the person decides to wake up? I thought 10 o'clock in the morning's

a reasonable time to be woken. 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 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. So did you consider his local connections? Did you know that he was a well respected... No, no. You weren't made aware of the fact that he's a cultural elder in... Well respected, well connected. No. No. He was an Aboriginal in a very drunken state

or very groggy state. That's all I knew him as. 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: Graeme Powell, on the other hand, was GSL's most experienced guard

but six months before he'd been suspended from his supervisor's job.

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

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 600ml of water for the trip. The police officers who were dealing with Mr Ward were officers who knew him. So they knew him as basically what you're saying, a good bloke? Yeah. Yeah.

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

It's 400 kilometres to Kalgoolrie Jail. The Mazda van was old and slow, as Nina Stokoe put it. Nina Stokoe had filled in GSL's vehicle check list earlier that morning, but there was no box to tick to say the airconditioning had been checked. At the inquest Mr Powell was asked: Both guards knew there had been ongoing problems with this Mazda's airconditioning 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 aircon 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. 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. The Coroner's expert was Gavin Lyons. 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. 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 56. There was a CCTV camera for the guards to monitor the prisoner in the back but Nina Stoke had noted in the checklist that it wasnot 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.

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 Ward's 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. Graeme 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. We don't treat animals like that. We don't treat our pets like that. People get put in jail for treating another creature

the same as Mr Ward was treated. 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. 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. How would you describe it from your experience?

Almost like walking into a furnace. Mr Ward was placed in a wheelchair 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.

We actually packed ice around him. 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?" 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. At 4:30 in the afternoon, Kalgoorlie Hospital declared that Mr Ward was dead. We worked on this patient for nearly an hour and we just couldn't get any life. (ALL CHANT) We want justice. We want justice.

16 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.

(ALL CHANT) We want justice. We want justice. Everything they've heard to date makes their anger stronger. The GSL guards should be charged with manslaughter,

what do you reckon? ALL: Yes. WOMAN: 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. This is the mother, the mother, she's suffering daily.

Justice must be served, changes must happen. And the people responsible from Laverton to Kalgoorlie has to be punished and charged because we all crying because our man elder is gone and 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 us Ngunyandurra people. He did a lot of good things in Warburton and throughout the Nyundurra lands. He was the next of the elders. Why did they have to do this, didn't do their duty of care. WOMEN CRY 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. 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.

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. 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 1,000km. They were disoriented, dehydrated and distressed.

He was shocked. No opportunity to urinate

during the journey, very little access to water, poor climate control. It's 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. Later that year, Professor Harding produced a report that warned with ominous clarity of the dangers and inhumanity of the system he'd inspected.

He noted the Department of Justice:

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

He noted there was: and when full it was:

He stated it was evident that: and quoted this pointed comment from a prison administrator. He was disappointed with the Government's response. Well, I twice notified the Minister in general terms

of my great concern about the health, safety and welfare of the passengers in the circumstances of these long transports in what I believe were unsuitable vehicles. But this didn't sufficiently resonate and nothing much was done at the time. 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 is clear and unambiguous about the type of Mazda used to transport Mr Ward.

The report specifically recommends the Mazdas: 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. 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?

Well, I mean it actually makes them criminally negligent.

If you could prosecute a bureaucracy this is what you would be doing. If there were something called bureaucratic manslaughter the Department of Corrective Services would certainly be prima facie guilty of that.

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. 14 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. About half of them were minimum-security prisoners who really - a phone call to the prison superintendent

would've allowed them out of the vehicle without restraints. 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. 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... To go in front of each other. Exactly, exactly. 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 sweatier as the day progresses. 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. Further Member statements, the Honourable Giz Watson.

Thank you, Mr President. I wanted to bring to the attention of the House some information that came to my attention... Giz Watson was the first to make the Sandfire incident public. They were not allowed to leave the vehicle at all. And, um, it seems to me, that this is an extraordinary circumstance,

which I am sure members won't have heard about via any other source than a statement such as this in the House. It seems to me it is totally unacceptable. It wasn't news to the-then Labor government. The Minister for Corrective Services had known for weeks.

When Giz Watson brought it up it was, in fact, no surprise to you?

No, I was aware of the incident. I became aware of the incident some days after it happened. It wasn't something you chose to make a press release about or let the general public of Western Australia know about it? Well, frankly no-one much was interested. But the following day there was this. SPEAKER: The Minister for Corrective Services. I wish to inform the House about an incident

involving inter-prison transportation of prisoners by the AIMS corporation.

The Minister went on to give this commitment - an incident like Sandfire would never happen again. It is intolerable that in this day and age

people should be subjected to such inhumane conditions and I have requested the department

that we scrutinise existing procedures to ensure that similar instances do not occur in the future. What did you make of that statement? Well, I took it on face value. I mean we have to. I mean we have to put faith in the umpire in the game, we have to put faith in the politicians who do these things. But, you know, the complaints continued and, of course, leading to a tragedy. Looking back on it, I think... ..they were just words in the wind. 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 the hearings. Mr Hughes, any chance of an interview with Four Corners?

No. No? John Hughes's 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. 3 means a death is quite possible, with the associated risk level to the company assessed as high. AIMS told the Department bluntly:

Do you think alarm bells should have gone off in the department that there is a risk every day a vehicle is taken out? Absolutely, absolutely. And it's incomprehensible to me why it wasn't treated with greater attention and urgency.

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

It didn't happen as fast as I would like it to have happened,

but, yes... Why? Why? 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. Well, I've thought about this in hindsight. Um...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 issue as acutely as I was. But it's your job to make your Cabinet colleagues aware of that. 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. 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. Well the report had a range of recommendations in it and, ah... But just to get back to the question, you were... The potential of the air-conditioning, as we know in hindsight, and no-one regrets what happened to Mr Ward more than I do

and without meaning to sound trite, it was a tragic incident.

They were warned and it's happened. And that's the tragedy. It shouldn't have happened. Six months before Mr Ward died, the AIMS corporation bailed out of providing the prisoner transport service. 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. I felt quite appalled actually. I 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've commented in the report that it was, yeah, I was very shocked by the whole thing. 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 the 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 non-stop for seven hours. And things get worse.

People was in the back side shouting, crying, 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, they're 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 I was there and I was thirsty, drinking a little bit of water because I was lucky - I was with this guy and I have a water. And they didn't stop for any breaks, no lunch, no breaks, nothing, and I have to, like, and, um, 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 I have to do it in the car. Over the 7-hour journey, none of the five detainees was given any food. Only Sayed Kamal and his cell-mates had any water to drink. GSL was found to be responsible for:

The report also found the van was unsafe. There were:

Did GSL accept that they had breached their duty of care in relation to those detainees? Ah, that's something you'd have to put to GSL, but my report outlines the concerns that I found and GSL would have to comment on that. They accepted your recommendations? Yes. And paid compensation to the people concerned? They accepted the recommendations and the findings. 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:

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. But it did, and worse. Four years later,

this is the same Tim Hall seen here walking into Mr Ward's inquest. You should be ashamed. ..the one who was in there. You should be guilty. You're part of it. We expect an apology by you folk. John Hughes is now the general manager for GSL in Western Australia. Over a year after Mr Ward's death, GSL has still taken no disciplinary action against Nina Stokoe and Graeme Powell, the guards who drove him on the day. At the inquest, Mr Hughes was asked why. His answer was extraordinary. How can it be that you can put someone in the back of a van for a 4-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? It's certainly surprising. What does it say about those procedures? What does it say? 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. 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. I'm Ian Johnson. Sorry for your loss.

Hi. My name's Ian Johnson. How are you? Dorothy. Hi, Dorothy. That's my sister, this one. And the niece. All the nieces?

Daisy Woods. Daisy. How are you? I'm sorry for your loss, Daisy. I don't know where Mum is. She still coming? There's somebody else still coming? Yes. Should I wait? OK. I'll just wait till others come. They're waiting for Mr Ward's widow, Nancy. My name's Ian Johnson. I just want to say sorry for your loss. Ian Johnson had a message for the broad family group. First of all, I just wanted to come along and say I am sorry for what has happened. I feel a little bit inadequate and 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.

He went on to deliver a familiar line - the department is now committed to ensuring it never happens again.

..making sure we make the changes to try and make sure this doesn't happen again. 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. Welfare checks, about obviously safety procedures inside the vehicles, about alarms that actually sound to tell you that something's actually gone wrong, but importantly, communicating with people who are being transported to make sure they are alright. Finally, it was good to hear the Commissioner say that as far as the department's actions go, he is responsible. Forget all the committees. At the end of the day I am the person that's responsible for the department and the actions of the department and I take that responsibility. Thank you. Thank you. Thank you.

..Four Corners. Hi. How are you? Look, you are saying you accept responsibility for what happened. Are you saying 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? 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. So do you accept... No, I am saying... Sorry. 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. Does that mean you are responsible for the fact that... I'm here to speak to family members... ..department's 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...

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 they asked me a question about who's responsible for the department, that's me. That's all I have to say. Can I ask you a question about responsibility? Do you feel you can say to the Ward family that the State did exercise a duty of care in relation to Mr Ward? No, I think we were negligent and I myself regard myself as personally responsible even if I'm not legally responsible. Have you met with the family? No, I was waiting until after the Coroner's inquest and I certainly had messages passed onto them on my behalf but, no, I haven't.

Are those messages saying sorry? Of course they're saying sorry. I'm sure that she was upset. But in the end, where does the buck stop? It's got to stop somewhere. (CHANTS) 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. 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? ABORIGINAL MUSIC .