Staff shortages and the lack of cell searches provided opportunity for an inmate at Auckland's Mount Eden prison to commit suicide, a coroner has ruled.
Wayne Hotton, 48, was a remand prisoner at the Mount Eden Correctional Facility when he took his own life in 2014.
A subsequent coroner's inquiry has since found that Hotton committed suicide in his cell.
Hotton was arrested on December 21, 2013, on drug offending charges and was remanded in custody to Mt Eden prison. This was the first time he had been incarcerated.
He was released from prison on electronic bail in February 2014, but later failed a drug test and was remanded back to Mt Eden prison in April that year.
On September 6, 2014, prison staff found Hotton is his cell unresponsive.
Staff are said to have immediately radioed for assistance and attempted CPR, but efforts to revive Hotton were unsuccessful.
Before taking his own life, Hotton wrote two letters; one to his girlfriend and another to the prison manager, a coroner's decision says.
The letters indicated that his death had nothing to do with prison, staff, or any inmate, and that there was "nothing anyone could have done or said" that would have changed his decision.
An inquest has found several issues surrounding Hotton's death, and determined that staff shortages, the lack of cell searches and an obscured camera provided him with the opportunity to take his own life while in custody.
Led by Coroner Debra Bell, the inquest found that Hotton had previously indicated to prison authorities that he had thoughts of self-harm and had been placed under intermittent observation.
Despite his history, Hotton's cell had not been searched for 25 days and routines for his unit were severely affected by staff shortages for the three days prior to his death.
Bell said the lack of cell searches meant items used in Hotton's death were not found and the standard to ensure prison safety was not met.
The camera in Hotton's cell was also found to have been obscured for a total of 15 days and was believed to have been covered in toothpaste.
Bell stated the lack of response to clear the camera was a missed opportunity that should have alerted authorities to precursory signs leading up to Hotton's death.
She said it was "difficult to assess the issue as to whether the staff shortages at MECF contributed to Hotton's death".
"There is no direct evidence before me as to the effect of the lack of staff shortages on him personally.
"However, given the environment in which he died, I am of the view that the lack of staff must have impacted on Hotton's well-being one way or another but I cannot go so far as to say that the staff shortages alone were responsible for Hotton's death."
At the time of death, Mount Eden prison - NZ's largest remand prison - was managed and operated by Serco, but by the time the inquest took place this management was no longer in place.
This change made it hard for the coroner's office to locate appropriate witnesses to provide evidence and also meant Serco was no longer in place to implement any of the recommendations made by Corrections management.
Due to this change, Bell has left the matter in the hands of Corrections which now oversees the prison.
Corrections held Serco accountable for the staffing issue and has since implemented increased staffing levels to ensure prison operations manual requirements are met. Extra training is also being provided regarding at-risk assessments.
In a statement, Serco said: "We were saddened by the death of Mr Hotton at Mt Eden Corrections Facility in September 2014 and sent our condolences to his family. We accepted the findings of the Inspector of Corrections' investigation and these have been confirmed by the Coroner."
Hotton had three children and is survived by his sister Lynda and father Peter.
Where to get help:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
Or if you need to talk to someone else:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youthline: 0800 376 633
• Need to talk? Free call or text 1737 (available 24/7)
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Samaritans 0800 726 666
• Rural Support Trust: 0800 787 254.