Coroner's inquest begins into death of Nicholas Evans

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The coroner's inquest into the death of Nicholas Evans began today in the District Court at Auckland.

In March 2015, Evans was a prisoner at the Mt Eden Corrections Facility, which was run by Serco at the time, and died three months later in hospital.

Evans had a ruptured lung and contracted pneumonia, which was compounded by the MRSA superbug. He was put on life support and died in June 2015.

His family engaged lawyers in the same year, believing Evans suffered assaults while in prison.

They said at the time they believed one assault was related to Evans being sent from Mt Eden to Nga Wha Prison in Northland at the end of May.

Sergeant Heather Ruddell, the inquest officer, said Evans died from septic shock due to pneumonia complicating chest drain insertion for spontaneous pneumothorax.

Two chest drains were used during his medical care and that appeared to be how the infection occurred, the court heard.

Ruddell said that, based on the report, the origin of the collapsed lung was difficult to determine given the time that had passed.

Investigating police were satisfied there are no suspicious or untoward circumstances, she said.

Australia-based Clint Bambrick, who has worked for Serco for a decade, spoke of the documentation he had seen from the time.

Bambrick said he could "reasonably infer" Evans was inducted into the CMS system, in which medical booking appointments could be made.

The inquest heard a prisoner who shared a cell with Evans, claimed he had shown Evans how to use the system.

Barrister Michael Okkerse, Evans' parents, said the prisoner had described Evans as appearing "naïve and vulnerable" and seeming "as if he did not know the ropes".

Okkerse claimed Evans had not been properly inducted until 49 days after his arrival.

The court heard that in May 2015, Evans told a physiotherapist he had been lifted and thrown on his back during an assault.

Bambrick said this should have been investigated but Corrections staff were not aware of that information at the time.

Bambrick said if this information was seen actions would have been taken to see if it could be substantiated but he did do not have that information which would have established categorically if an assault had occurred.

The court heard a prisoner said Evans told him he had been assaulted by Black Power prospects because he could not pay for tattoos they had done.

He had been "all crouched up" at the end of his bed complaining of the chest pain.

In 2015 it was revealed Serco was fined $300,000 in the year leading up to the 25-year-old's death for breaching its contract with the Government.

The breaches at Mt Eden Correctional Facility for the 2014/15 financial year included understaffing, failing to give "minimum entitlements" and not giving adequate notification about incidents.