Rough prison guard tactics led to the death of a Loddon Prison inmate whose family is now considering suing the state for negligence.
Subscribe now for unlimited access.
$0/
(min cost $0)
or signup to continue reading
Underworld figure Hizir Ferman died an hour and a half after he was forcibly removed from his cell in July 2016, when officers used tear gas, handcuffs and crushed him beneath a shield.
The 36-year-old died during the operation to move him from a Loddon Prison annexe in regional Castlemaine to Barwon Prison.
Tear gas exposure, agitation and restraint contributed to his death, Coroner Rosemary Carlin found on Friday. "If the planning and co-ordination of the event had been better, the method of restraint not unsafe, and the after-care administered by nurses adequate, his death may have been prevented," she wrote.
Family members of the man, including his sister Belle Ferman and aunt, were in court to hear the findings.
Their lawyer Jeremy King said they might sue over the death.
"The findings definitely open the way for a negligence case," he said. "They had to fight from the outset to get justice for Hizir and they hope his death is not in vain."
The decision to move Ferman to a maximum-security prison came after he assaulted two prison guards, knocking out one of the officer's teeth and breaking his nose.
"I am satisfied that the way Hizir was restrained was significant but without the prior struggle or the CS gas exposure, he presumably would not have had an increased respiratory demand and the manner of restraint may not have been lethal," she wrote.
Specialist guards used tear gas in the cell, which prompted a violent struggle between the prisoner and multiple officers before he was restrained and dragged to the bathroom.
For six minutes, officers continued to restrain Ferman as he had the gas washed from his face.
"It was therefore inherently unsafe to restrain him in the prone position for a prolonged period, let alone with his hands cuffed behind his back, a shield on top of him and pressure applied," Ms Carlin said. Despite Ferman losing control of his bowels, guards continued to restrain him and the coroner slammed their decision.
"It did not occur to any of them that Hizir may have simply been struggling to breathe. Indeed, it did not occur to any of them that Hizir may have been fighting for his life."
It was only after the inmate vomited that a supervising guard asked for medical attention and took him outside the building.
The coroner also criticised the nursing response because they were unprepared for the situation and failed to recognise Ferman was critically ill.
The official cause of death was "cardiorespiratory arrest in the setting of acute agitation and physical and chemical restraint". Ms Carlin recommended better cell extraction training for guards and updated online training about positional hypoxia.
She also recommended a review of the layout of bedroom configurations to allow guards to view or enter in emergencies, and fact sheets for medical staff on restraint and positional hypoxia be updated.
Have you signed up to the Bendigo Advertiser's daily newsletter and breaking news emails? You can register below and make sure you are up to date with everything that's happening in central Victoria.