A coroner has concluded that "inhumane" treatment led to the death of an Aboriginal elder in the back of a prison van on a scorching day in outback Western Australia.
West Australian Coroner Alistair Hope said the death of Mr Ward, 46, whose first name cannot be released for cultural reasons, was "unnecessary and avoidable".
Mr Hope criticised the company that owned the van and transported Mr Ward on a 360km journey between the Goldfields towns of Laverton and Kalgoorlie, and accused its custodial guards of colluding in their evidence.
He found the company, Global Solutions Ltd (GSL), the two guards, and the Department of Corrective Services had all contributed to Mr Ward's "terrible death" on 27 January last year.
The coroner found the father of four, from the Goldfields town of Warburton, died of heatstroke when he succumbed to temperatures of 50 degrees celsius inside the van on a searing day.
The court was told that after being picked up for drink-driving the day before, Mr Ward was transported in a van whose prisoner's compartment had no air-conditioning and little air flow.
Mr Hope said the guards provided Mr Ward with only a 600ml bottle of water and did not check on him throughout the journey.
The hearing was told that when Mr Ward eventually arrived unconscious at Kalgoorlie hospital, his body was so hot that staff had been unable to cool him down.
Even after an ice bath he had a body temperature of 41.7 degrees.
He had a third degree burn to his stomach from lying on its hot metal floor.
Mr Hope said the department had failed to provide GSL with proper means of transport and that the vehicle was "not fit for humans".
West Australia Attorney-General Christian Porter said action had already been taken to prevent another "tragic incident" and pledged $A3 million and a rollout of 40 new custodial vehicles by December 2010.
About 40 protesters demonstrated outside Perth's Central Law Courts, where the coroner delivered his findings.