Inside a cell at Christchurch Men's Prison (File photo). Photo: Luke McPake / The Wireless.
Prison staff's failure to answer an emergency call from a cell intercom and a subsequent delay in starting CPR potentially contributed to the death of a Christchurch inmate, a coroner has ruled.
The 67-year-old man, whose name was suppressed by a court, died of heart disease at Christchurch Men's Prison in Templeton in 2022.
When his cellmate woke to find him gasping for air he tried to raise the alarm but the emergency intercom call went unanswered.
In findings released on Thursday, Coroner Dan Moore said there had not been an adequate explanation as to why no-one responded to the call.
"In my assessment, the intercom going unanswered at the time of (the man's) death is a significant failure on the part of Corrections," he said.
"In-cell intercoms exist for precisely this kind of situation. Due to their confinement, it is the only means by which prisoners can raise alarm in an emergency. It should be expected that prison staff are alert and respond to calls in a timely manner."
The report said there was a gap of approximately 18 minutes between the man's call for help via the intercom and the start of CPR.
"Though it is not possible to say for certain whether (the man) would have survived had the intercom been answered immediately, I am satisfied that this delay has potentially contributed to (his) death," the coroner said.
When the man arrived in prison in June 2022 he was assessed by a nurse and found to have hypertension, along with other health issues.
His cellmate said the man would often wake him at night when he was having difficulty breathing.
The man was assessed several times by a prison nurse and had submitted two complaints about a lack of medical treatment by hospital staff.
The man and his cellmate were in the Kauri Wing, which was not staffed overnight, although prison officers did several visual checks of each cell, the last of which was at 5.30am.
The cells were fitted with intercoms for emergencies, connecting to "control rooms".
On the morning of the man's death in July, the cellmate woke to find him gasping on a shelf he had climbed on to get closer to the window for fresh air.
The cellmate used the emergency intercom to try to contact staff at 6.39am but the call went unanswered.
The man then fell from the shelf to his bed and continued gasping for air, before his breathing slowed and eventually stopped.
His cellmate started banging on the door to try to get the attention of prison staff.
At 6.52 am, an officer came into the wing and heard prisoners yelling. She went to the cell and saw that the man had collapsed on his bed.
The officer then left to get help because of a policy that at least five staff members must be present before opening a double-bunk cell.
Attempts were made to revive the man, but he was pronounded dead at 7.21am.
Similar jail cell death
Coroner Moore was critical that changes had not been not made after a similar death five years earlier at Mt Eden prison.
In 2017, Tuan Anh Nguyen's cellmate tried to get help using a call bell that went unanswered for 1.5 hours.
At the time, the coroner recommended changes to ensure emergency calls did not go unanswered.
Coroner Moore said Corrections had updated part of its prison operations manual on in-cell alarms since the man's death in 2022.
"Had those changes been in place and complied with in (the man's) case, it is likely that there would have been a more rapid response from prison staff. It is not possible to say for certain whether this would have prevented his death, but it may have increased his chances of survival," he said.
In a statement provided to RNZ, one of the man's children said no-one shouold be denied their basic human rights while in custody, regardless of their crimes.
"The emotional impact of his death has been devastating. We are a large whānau, and the effects have rippled across four generations - our children and grandchildren included. This loss, and the circumstances surrounding it, has caused profound and ongoing distress," they said.
They said their father had been denied the right to be treated with humanity, diginity and respect.
The family's grief had been compounded by the lack of communication and accountability from Corrections and the lack of an apology, they said.
"We were not informed appropriately - we learned of our father's death through another inmate before police contacted us. This failure alone has had a lasting impact on our whānau."
They said they were deeply concerned lessons did not appear to have been learnt after the death of Nguyen and much of what the family learnt about their father's final days came from his traumatised cellmate.
"He described repeated breathing difficulties over several days, escalating distress and unanswered calls for help on the morning our father collapsed," they said.
The family member said the coroner's findings confirmed their belief there was a serious failure of care and they were not reassured it could not happen again.
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