Otago prison inmate’s death was preventable, coroner says

A coroner has found the death of an Otago Corrections Facility inmate who was hit by another prisoner in an exercise yard was preventable.

Grant Steven Bowden, 47, was struck on 3 November in 2017, fell backwards, hit his head on concrete and was knocked unconscious.

Dunedin Hospital staff saved his life by preventing his swollen brain from being crushed against his skull, although it left Bowden with a traumatic brain injury and disability that meant he could not swallow liquids or food.

He was transferred to a facility in West Auckland in May 2018 and in December died of multi-organ system failure at Waitākere Hospital after developing a chest infection.

Nyal Heke – the prisoner who struck Bowden – was charged with grievous bodily harm and had 15 months added to his sentence, which he was still serving.

An inquest was heard in Dunedin in January and April 2023, where prisoners on Bowden’s wing told the court they had asked Corrections staff to relocate him because he was mentally unwell and “unpredictable”.

Heke told the inquest “a man is dead because of me,” and that it still gave him nightmares.

His conviction came before Bowden’s death and the laws in place at the time prevented his charge or conviction from being upgraded or re-tried afterwards.

Coroner Alexandra Cunninghame found Bowden’s death was preventable, in findings publicly released today.

Record-keeping at the Otago prison was “unsatisfactory” and the offender notes system was not maintained, she found.

“Corrections was unable to locate documents which, if completed, should have been stored on [Bowden’s digital] profile,” the report said.

Some Corrections staff meetings were informal and were not recorded, leaving staff to rely solely on what they had been told about prisoners, it said.

Corrections was also unable to identify who was the senior Corrections officer on Bowden’s wing at the time of the fight.

“This raises questions about the level of organisation that was in place on the ground,” the Coroner said.

Another prisoner said he had told a Corrections officer that Bowden – who had schizophrenia – had been trying to start fights with others on the wing the day before he suffered the blow.

“[The Corrections officer] advised [the prisoner] to keep the information to themselves,” the report said.

“The failure to maintain an accurate and reliable system for recording, collating, and communicating information… leads to a situation where risks, particularly cumulative risks, are not identified or managed,” Cunninghame said.

“If [information about Bowden’s mental health] was discussed, there is no evidence that its significance was appreciated, or that the need to watch Bowden closely was acted on.”

Bowden’s risk was not properly identified by the prison’s initial assessments because it did not account for his schizophrenia, the report said.

Staff shortages were also mentioned in the report as putting “pressure” on Corrections officers.

“ad 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 Bowden might have been different,” it said.

The first officer arrived at the yard 53 seconds after he was dealt the blow.

The Coroner acknowledged staffing levels remained strained and “Corrections is operating in an environment of budget and resource challenges”.

The inability to manage Bowden in a way that removed or minimised the risks his behaviour posed suggested a review of legislation and policy was needed, the Coroner said.

She recommended Corrections carry out reviews and audits to ensure its policies and procedures “reflect its human rights obligations… particular those in the most vulnerable categories in prison settings which includes prisoners with mental health needs”.

This included the management of prisoner information and training staff in the importance of recording and referring relevant prisoner information up when required, the report said.

A separate recommendation was made to broaden Corrections’ induction screening and risk assessments to include physical health, mental health, safety and security needs, in line with the Corrections Act 2004.

Cunninghame said she was satisfied Bowden had been provided appropriate assessment, treatment and management by the prison’s healthcare teams.

She also found collaboration between Corrections and Health Southern’s (then Southern DHB) mental health services was appropriate.

However, the coroner recommended Corrections “explores establishing inpatient facilities for prisoners experiencing mental health and addiction issues throughout New Zealand” in future.

Any investigation into the viability of inpatient prison facilities should involve consultation with Te Whatu Ora Health New Zealand (in particular, New Zealand Forensic Psychiatry Advisory Group), Māori, and those with lived experience of mental health issues and their families, the report said.

A damning 2023 report by the Chief Ombudsman urging Corrections to urgently fix workplace and leadership problems, while welcome, did not resolve the issues that had been identified at the inquest, the coroner said.