Corrections condemned by Coroner over death of Christchurch prisoner Kodi Bennett

Kodi James Bennett died in prison just months before his release. Photo / Supplied

Warning: This story discusses self-harm and suicide.

Kodi James Bennett had harmed himself in prison before.

The young man was doing better though. He had been moved out of an At-Risk unit several days earlier and it had been 12 days since he had tried to take his life with a personal care instrument.

But, later that day he used the same instrument he previously tried to hurt himself with and died after being left unobserved in a shower stall at Rolleston Prison in April 2016.

In a comprehensive report released today, Coroner Mary-Anne Borrowdale has condemned the actions of Corrections, describing some steps taken by staff as “reckless and irresponsible”.

In a rare move the coroner has permitted the publication of the circumstances of Bennett’s death, saying it is crucial to understanding her recommendations.

Corrections has in response accepted the recommendations and findings and acknowledged it let Bennett down.

“We have a duty of care to people in prison, which we take extremely seriously,” Emma Gardner, director of mental health and addictions, told NZME in a statement.

“In 2016, when Kodi died, the systems and processes we had in place let him down, and for that we unreservedly apologise.”

Bennett was in prison for dishonest offending, with the sentencing judge admitting the man was not a professional burglar but had been living rough and without money.

The 25-year-old would have walked away a free man just three months later in July 2016 if he had not died.

His loss is still felt by his family.

In a statement given to NZME, a family member said they didn’t want to comment on the report, instead describing how much the beloved brother and son is missed.

They find comfort in the memories of a young man who was loved by many.

“I cannot put into words how I feel about the loss of my son, Kodi,” his father, Allan Bennett, told NZME. “Especially under the circumstances.”

On April 3 while housed in the general population at Christchurch Men’s Prison, Bennett made a serious attempt to end his life. He received medical treatment at Christchurch Hospital and was discharged the next day.

From April 4 to 11 Bennett was housed in the At-Risk unit at Christchurch Men’s Prison, a place described by his forensic prison psychiatrist as “just a really ghastly environment”.

Bennett was there for his own safety and to be under regular observation, but on April 11 he was moved to Rolleston Prison, where, just days later, he died.

He was moved because, according to the unit, his recovery was going well, and he didn’t need constant care.

His psychiatrist said Bennett should be under “close observation and vigilance” regarding his moods.

While at Rolleston, Bennett was assessed to be “not a risk”. He was given a personal care instrument to have in his cell, the same instrument that he had used in a suicide attempt just less than two weeks earlier.

Rolleston Prison. Photo / APN

Coroner Borrowdale made adverse comment on why Corrections would provide the instrument to Bennett and for failing to treat Bennett as a prisoner at risk to himself while at Rolleston.

“Handing Kodi a demonstrably dangerous instrument – which he had already used to seriously harm himself - was a reckless and irresponsible step, in respect of a prisoner who was at elevated risk.,

She found multiple failings by the Department of Corrections, including the fact staff had given Bennett the same “demonstrably dangerous” instrument he had used in a suicide attempt weeks earlier.

Coroner Borrowdale found Corrections had failed to adequately supervise Bennett after he had harmed himself, and on the day he died. He was found dead at 5pm on April 15, 2016. He had not been checked on since midday.

She also condemned Corrections for failing to advise Bennett’s family he had seriously harmed himself at the beginning of April 2016, and to assist them to visit him after.

“I expect that many ordinary New Zealanders would be surprised to learn their loved one, who is imprisoned, could be near-fatally injured and they might not be advised, depending on the ‘case-by-case’ decision made by the supervising Corrections officers,” coroner Borrowdale said.

The thorough and lengthy findings, which span 144 pages, contain a plethora of recommendations for Corrections and adverse comments on the death.

These include improving the identification and observation of higher-risk prisoners, improving the therapeutic environment in at-risk units and further restrictions on access to personal care instruments.

Coroner Borrowdale also recommended visitor access for “seriously self-harming” prisoners be prioritised.

Since Bennett’s death in 2016, Corrections has made some positive changes, however, the coroner said she was “unpersuaded” communication of prisoner risk and health status within the department had materially improved.

“There is still an over-reliance on verbal communication, something which has regularly featured in coroners’ findings as an area of weakness that has contributed to prison suicide,” Coroner Borrowdale said.

It was also recommended Corrections and Te Whatu Ora Health New Zealand ensure urgent care for prisoners who have presented due to self-harm or suicidality.

Gardner, director of mental health and addictions, said Corrections were working through the recommendations of coroner Borrowdale.

In the seven years since Bennett’s death Corrections had made a “wide range of changes”, Gardner told NZME, specifically to support people with mental health issues with an aim to reduce self-harm and suicide in prisons.

Government funding has allowed Corrections to expand its support teams for people with mental health struggles across a number of corrections facilities throughout the country.

“We are committed to learning from the findings in the Coroner’s report so we can prevent these events happening in the future,” Gardner said.

Hazel Osborne is an Open Justice reporter for NZME and is based in Te Whanganui-a-Tara, Wellington. She joined the Open Justice team at the beginning of 2022, previously working in Whakatāne as a court and crime reporter in the Eastern Bay of Plenty.