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A chain of mistakes by the Corrections Department, Chubb Security and the Auckland Central Remand Prison led to North Shore teenager Liam Ashley being choked and kicked to death in the back of a prison van.
A Corrections report into Liam's death, released yesterday, said it could have been avoided.
Deficient practices, incomplete and partly inaccurate information, missed alerts and confusion contributed to 17-year-old Liam being wrongly handcuffed to his killer, adult prisoner George Baker on August 24.
Despite accepting that the system failed Liam and his family, both Corrections Minister Damien O'Connor and department chief executive Barry Matthews yesterday resisted calls for resignations by themselves or Corrections staff.
Mr O'Connor said Liam's death was "brutal and senseless" and he had enormous sympathy for the Ashley family. Prison transfers would be overhauled, and his job was to oversee that.
"I hope the Ashley family can be reassured that we are doing everything we can to prevent similar tragedies occurring in the future," Mr O'Connor said.
"There has been no one person identified as being at fault. It was a systems fault. I have a responsibility as the minister to make sure that the systems cannot allow this to happen ever again."
Liam's mother, Lorraine Ashley, told TV3 the family wanted heads to roll.
"It's like a pyramid. Someone has to be held accountable. Not just 'we're sorry we've made a mistake' - that's not good enough.
"They're incompetent, through and through," she said.
Prime Minister Helen Clark said Liam's death was unacceptable and avoidable. As Minister, Mr O'Connor was "responsible but not to blame", and she had faith in his ability to reform Corrections.
"I have found Damien O'Connor to be a very compassionate and humane Minister of Corrections and I believe that he should fix this."
Mr Matthews said he had asked Mr O'Connor if he still had confidence in him as Corrections chief executive.
"He said that he does and, as a result, I'm now getting on with the job of implementing the [report's] recommendations."
Chubb managing director Tom Nickels said the company's own report into Liam's death was completed two weeks ago and had been given to Corrections. It would not be made public but would be given to the Ashleys if they wanted a copy, he said.
"When they are ready we look forward to an opportunity to meet with them to try and provide answers to their questions."
The guards had not faced disciplinary proceedings, were still Chubb employees, and continued to escort prisoners, Mr Nickels said.
"We will take the report and undertake one more step in our review and say 'what do the findings mean for our officers?' We need to do that."
Chubb would comply with any changes Corrections asked it to make to prisoner transport, Mr Nickels said.
National justice spokesman Simon Power doubted whether Mr O'Connor could solve the Corrections Department's problems.
"We have seen mistakes not only at the ground level, operational level, but also at the policy and medium to senior management level," Mr Power said.
"Everybody is happy to accept with hindsight that mistakes were made in the department but nobody is prepared to take responsibility ... the minister himself must take some political responsibility for the shortcomings of his department."
Greens justice spokesman Nandor Tanczos said an independent prisons inspectorate should be set up to ensure there could not be another Liam Ashley case.
"There has got to be some culpability because the argument that various parts of the system failed but no one is actually responsible I don't think is tenable. There is a young man who is dead and people have to take responsibility for that."
Mr Matthews said he had met the Ashleys on Friday, presented them with the report, and apologised on behalf of the department and Chubb.
"I have made it very clear to the family that we will accept the recommendations ... to ensure that as far as humanly possible we will prevent a recurrence of what occurred.
"We have not hidden any of the facts, albeit that some of them are stark and not easy to read."
How Liam Ashley's fatal prison van journey unfolded
Who was Liam Ashley?
A 17-year-old from Beach Haven on Auckland's North Shore. A long-time sufferer of attention-deficit disorder, his misbehaviour had escalated to offences like burglary, mainly against his mother.
His parents had decided to refer him to the justice system leaving the courts and prison to deal to him in a "tough love" way, feeling they had exhausted all other means.
Who was George Baker?
A 25-year-old man who killed Liam in the back of a Chubb truck on August 24. He had spent almost all of the last seven years in prison or psychiatric care after a violent home invasion on a woman pensioner and was back in custody after stabbing another North Shore youth and threatening to kill witnesses in the case.
Were they meant to be shoved in a prison truck compartment together?
No. Chubb follows explicit regulations that say those under 18 and adults should be kept separate "where practicable".
So there was no other option but to have Liam in with adults?
Actually, there was. The report found there were different configurations of prisoners that could have kept Liam separate for the entire fateful journey from the North Shore District Court to the Auckland Central Remand Prison.
So what happened?
A guard from Chubb, which has the contract with Corrections to transport prisoners in Auckland, decided to stick them in together because it was more convenient when it came to dealing with the security risk of all the prisoners in the van - it was easier to have them together than having to shuffle prisoners in and out at stops to keep the under-18s separate. The report says the Chubb process of doing this had developed over time. The report says this process was "deficient".
Didn't the Chubb guards notice anything was going on during the attack on Liam?
No. Even though an unnamed Chubb guard put Baker in the front compartment to "keep an eye on him", he says he didn't look back through the window once during the 21-minute journey. They say they didn't hear anything either, including Liam's head being banged against a steel seat.
So is it all Chubb's fault?
Not according to the report. Chubb got incomplete information on which to make a decision from the Auckland Central Remand Prison the morning Liam was picked up. The report describes the guards' decision as "understandable".They didn't know he was defined as "vulnerable". Nor did they know Baker was an "at-risk" prisoner also meant to be kept separate.
So Auckland Central Remand Prison staff are also to blame. Does it stop there?
No. Even the very contract between Corrections and Chubb wasn't up to scratch. It wasn't updated to take into account changes in the law. New provisions requiring prisoners under 18 to be segregated "where practicable" were not clearly expressed in the contract. This was because of "confusion" between different departments at Corrections.
What now?
The report says Corrections needs to issue specific guidelines on the handover of prisoners under escort, update its contract with Chubb and issue guidelines in separating youth from adults.
What do Liam's family think?
Ian and Lorraine Ashley say they cannot accept the incompetence that led to Liam's death, sheeting home responsibility to Chubb, Corrections and the Government. They say his death arises from a mix of the Government trying to save money and Chubb trying to make money. They are disappointed that not one individual has been held responsible.
