The Northern Territory Coroner has found a prisoner "may not have died" if proper procedures had been followed while he was driving an off-road buggy at the Darwin prison.
Coroner Greg Cavanagh also called on the NT government to fund a series of upgrades at the prison following an inquest into the death of 31-year-old Benjamin "Benny" Watts.
Mr Watts died after crashing an all-terrain vehicle (ATV) into a concealed metre-high mound of dirt on a track in the horticultural precinct of the prison in May 2020.
The mandatory inquest heard that Mr Watts, an experienced worker in the prison, was driving at high speed at the time of the crash.
The Polaris ATV buggy had a top speed of 60-70 kilometres per hour.
In findings released on Thursday, Mr Cavanagh said the prison had not followed various safety procedures set out in the owner's manual for the vehicle which warned of the possibility of injury or death.
"There were no cab nets fitted … There were no helmets available to those operating the Polaris," Mr Cavanagh said.
"The horticulture section had their own Safe Operating Procedures … [but] there was no mention of seatbelts, helmets, eye protection or cab nets."
The inquest heard evidence during a two-day hearing in March indicating that prisoners were told to wear seatbelts when operating the ATV buggies, but that they "generally" did not.
"But the fundamental issue is that the Polaris was a fast and potentially dangerous vehicle … it was a hazard that the prison authorities had introduced to the workplace without addressing the risks."
Mr Cavanagh found the treatment and supervision of Mr Watts while working at the prison "should not be criticised" but given the dangers presented by the vehicles in the horticulture section, "the level of care provided was insufficient".
Acting Corrections Commissioner David Thompson had told the inquest that since the crash, helmets had been purchased, seatbelts made mandatory on prison vehicles and the buggies no longer turned on unless the seatbelt was engaged.
The Polaris vehicle has since been decommissioned by the prison, but some recommendations from an internal safety review were yet to be implemented, the inquest heard.
"It was said [during the inquest] that implementation was subject to approval of the necessary resources, that Corrections was still awaiting a decision on whether those resources would be funded," Mr Cavanagh said.
"In my opinion the implementation of those recommendations should be a priority."
When contacted by the ABC, Corrections would not say how many safety recommendations were yet to be addressed.
Attorney-General Selena Uibo has been contacted for comment.
Mr Cavenagh praised two of Mr Watts' fellow prisoners who were driving a separate ATV at the time of the crash, describing their resuscitation efforts as "nothing short of heroic".
At the time of his death Mr Watts had an open security rating and was "likely" to be granted parole less than three weeks after the day he died.
The inquest heard Mr Watts died while working his final shift inside the prison, as he was supposed to begin working in the community three days later.
In an earlier statement his sister Tamara Willcox said his family believed he would have made significant changes to his life had he got the chance.
"In his passing we will never get to see if Ben would make that change and reach his full potential and it is for this lost time with him that we mourn."
