Grant Steven Bowden, 47, died at Waitakere Hospital, in Auckland, on December 28, 2018, after a serious prison assault resulted in a head injury.
Mr Bowden had been assaulted at the Otago Corrections Facility more than a year earlier.
Last year, a 10-day inquest into Mr Bowden’s death was held by Coroner Alexandra Cunninghame, in Dunedin, and her findings can be published today.
Ms Cunninghame found the death was preventable and she made five recommendations to the Department of Corrections.
She highlighted the department’s "somewhat ad hoc system of record-keeping", noting there was "no single repository for all of the information about Grant’s risk".
"Information that was intended to be passed from health staff to custodial staff was either not acted on, or was acted on but without any formal record of the actions being made," she said.
Counsel for the department acknowledged following different policies and procedures could have changed the outcome for Mr Bowden, but said "this would require significant changes to resourcing or to legislation".
On October 16, 2017, Mr Bowden was remanded in custody on burglary charges.
The inquest heard Mr Bowden had struggled with his mental health since his late teenage years, was eventually diagnosed with schizophrenia and was resistant to treatment.
"His illness was severe and manifested in profound thought disorder and delusion, grandiose and bizarre ideas ... which had included threats of violence and assaults," Ms Cunninghame said.
Mr Bowden was taken to prison and a risk assessment on arrival said he denied any thoughts of self-harm, but appeared delusional and needed a forensic review.
He was in the at-risk unit and later was seen by a registered nurse, who noted he was agitated and angry.
Staff said they would move Mr Bowden to a safer and more secure cell within the unit.
On October 25, a senior Corrections officer said Mr Bowden asked to be moved to a mainstream unit.
The Corrections officer told the inquest he was "constantly" requesting this.
He was assessed by a forensic nurse, who thought moving him to a mainstream unit was "worth a try".
"A low tolerance should be placed for his return to the [at-risk unit] if it is thought necessary," the nurse said.
That day, Mr Bowden was moved into a mainstream remand wing.
"Once Grant was identified as not being at risk of hurting himself or attempting suicide, he was managed like any other remand prisoner with health needs," the coroner said.
A prisoner in the remand wing with Mr Bowden described him as "weird" and "provoking" and said everyone in the unit "gelled together except for him".
On November 2, Mr Bowden’s assailant, Nyal Heke, approached a Corrections officer and said Mr Bowden was picking fights with other prisoners, and they wanted him out of the unit.
The next day, Heke and Mr Bowden were in the exercise yard when Mr Bowden threw a mock punch.
Heke punched back and the pair began shadow boxing before Mr Bowden was hit in the head twice.
The second blow knocked the victim into the concrete wall and the pair separated.
Minutes later, Heke approached Mr Bowden again and they continued sparring.
During this exchange, Heke could be seen looking over his shoulder for Corrections officers.
"Heke aims three punches at Grant in a ‘right-left-right’ combination.
"The last punch connects, and Grant falls backwards on to the floor, hitting his head on the concrete," Ms Cunninghame’s findings said.
The first Corrections officer arrived at the yard less than a minute after Mr Bowden collapsed and an ambulance was called soon after.
Staff did not see the fight developing.
"Had staffing levels allowed for a Corrections officer to be tasked with monitoring the CCTV cameras of the exercise yard all of the time, the outcome for Grant might have been different," Ms Cunninghame said.
Heke pleaded guilty to causing grievous bodily harm with intent to injure and on October 30, 2018, he was sentenced to 15 months’ imprisonment.
Ms Cunninghame recommended Corrections review policies and procedures "to ensure that they reflect its human rights obligations".
It should audit and review its systems around prisoner information.
She recommended that training on the importance of recording and elevating prisoner information continue.
Corrections should ensure assessments, including the at-risk assessment process and any management plans that followed, addressed all risk factors.
The coroner also recommended the department explore establishing inpatient facilities for prisoners experiencing mental health or addiction issues.
Ms Cunninghame ended her findings by thanking prison staff.
"Prison staff work in a challenging environment, and I know that they can and do make contributions to improve the welfare and circumstances of prisoners in their care.
"Grant’s reality was different to that of most people, and sadly, especially in later years, his life became defined by his illness.
"However, through the evidence, it was possible to see that he maintained a sense of humour, and that he approached the world with curiosity."
Timeline
Oct 16, 2017: Grant Bowden is remanded in custody on burglary charges.
Oct 25: Moved from Otago Corrections Facility’s at-risk unit to remand population.
Oct 27: A nurse notes Mr Bowden seems "anxious and shaky".
Nov 3: Nyal Heke punches Mr Bowden, whose head slams into concrete when he falls.
Nov 16: Patient is discharged from intensive care.
May 3, 2018: Mr Bowden is transferred from Dunedin to a residential facility in Auckland.
Oct 30: Heke has 15 months added to his jail term.
Dec 24: Mr Bowden is hospitalised after developing a severe chest infection.
Dec 27: He dies in Waitakere Hospital from multiple organ system failure.
