Failure to pass on a family's concerns about an inmate's state of mind - or to notice that a cell's CCTV camera had been covered up for 12 hours - contributed to the deaths of two Northland men at Ngawha Prison.
Northland Coroner Brandt Shortland led inquests this week into the deaths of George James "Jimmy" Little, a 48-year-old from Paihia, and 20-year-old Eruera Henare Murray from Kamo.
Both died while in custody at Northland Region Corrections Facility, Mr Little on March 6, 2012, and Mr Murray on July 9, 2011.
Subsequent investigations revealed cell checks, which could have alerted staff earlier, had not been properly carried out. Both men were found to have died only when their cells were unlocked in the morning.
The men were alone in their cells at the time and there were no suspicious circumstances.
Mr Little's case showed no formal system existed for passing on concerns raised in court, first to the security company responsible for prisoner transport, and then to prison staff.
The investigation into Mr Murray's death revealed cells at Ngawha had been modified without official approval and that no one was responsible for monitoring the CCTV cameras in the "separates unit" where he was being held. The fire sprinkler in his cell had been deactivated and the alarm was not working.
Family members, Corrections staff and Prison Reform Society representatives attended the emotionally charged hearings at Kaikohe District Court on Wednesday.
The inquest heard that Mr Little returned to Northland in 2011 with his family, after 10 years in Japan. He was arrested after a domestic incident and appeared in court on March 5, 2012. Mr Little's siblings were concerned about his state of mind and feared for his wife and children, who were planning to return to Japan, so the judge denied bail.
However, those concerns - and the fact the judge was considering calling for a full psychiatric report - were not passed on to prison staff. A risk assessment, carried out for each new prisoner, did not raise any flags. He died some time after 3am the following morning.
Mr Shortland said it appeared the handover process, from police to court to prison, worked on an informal basis.
"Whether information gets passed on is a lottery ... The information passes through so many people that it gets lost, and that is what has caused this tragedy. We don't want to see this happen to another family."
Corrections chief custodial officer Neil Beales said a nationwide programme, Joining Forces, was improving co-operation between police, courts and corrections.
Mr Murray was jailed in 2009 and transferred to Ngawha in 2011. He was put into the ''separates unit'' following damage to prison property.
Peter Williams, of the Prison Reform Society, was critical of conditions in the unit.
''He had five minutes a week on the phone to his loved ones and he's all alone, a young boy of 20, locked up in a barren cell for 23 hours a day.''
Aunt Christina Edmonds, of Poroti, wanted to know why no one had "got off their chair" to check why the camera in Mr Murray's cell had been covered for almost 24 hours.
"He was taken from his whanau for doing things that were wrong, and fair enough, but we expected he would be kept safe ... There were little holes in the system and for Eru they all lined up. For Eru it was catastrophic."
Mr Beales said Corrections had fallen well short in its care of Mr Murray. A raft of changes had been carried out since then, including a check of all prisons in the country for unapproved modifications. Cells had been changed to make them safer and a telephone had been installed in the separates area so inmates could contact their families. Three staff had been disciplined.
Mr Little's hearing will be continued. Mr Shortland's findings on Mr Murray will be released at a later date.