A 14-year-old girl with Down syndrome died choking on a piece of meat in Gloriavale Christian Community while shut in an isolation room.
Prayer Ready was in an isolation room with the door handles disabled to prevent people getting in and out when she choked on her dinner, according to a coroner's report into her death.
She was accompanied by her mother Sharon Ready, who was caring for four other children with their father Stephen Ben-Caanan. They were put in the isolation room to stop infection spreading after their baby brother had been hospitalised with what Gloriavale described as an "infectious and dangerous disease".
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In a statement to Police, Prayer's mother said she thought her daughter was eating the beef schnitzel too fast and then saw that she was choking.
Prayer started walking towards her and led her to the bathroom.
"I realised she was choking and she was still standing and conscious. I wanted to do the Heimlich. I called out to Stephen who tried doing it but it didn't work. Stephen then went to go and get some help."
The adults were unable to get out of the room through the door due to pieces of the door handles being purposely dismantled, but Ben-Caanan crawled out of the window.
A number of people arrived including Prayer's father Clem and brother David, but she was unable to be resuscitated.
The family said in a statement to coroner Marcus Elliott that they had never been told by medical professionals Prayer could be at risk of choking and she had always recovered from choking in the past.
Prayer's mother described her as a "happy child who had a happy life".
Coroner Elliott ruled it was a tragic accident and he did not think the fact people could not enter or exit the room contributed to her death. He said members of the community had been able to enter the window easily and had been told a chair had been put under the window to act as a step.
However Gloriavale said following Prayer's death it had stopped disabling the doors to the isolation rooms. It had also had training on using Magill forceps to remove foreign objects and had obtained a pair of the forceps which were suitable for removing things from the throat.
A former Gloriavale member told Fairfax sick people were kept in the isolation room to prevent illness spreading in the small West Coast community. It was not uncommon for pins from the handles to be removed so people could not get in and out.
The Ministry of Health is reviewing its guidelines relating to the management of children, young people and adults with Down syndrome to include specifically mentioning choking risk.
Interim suppression on the coroner's report was granted in October 2015, but lapsed today.
A Gloriavale spokesperson declined to comment at this time.
Neville Cooper has been the leader of the isolated community for over 40 years. He served 11 months in prison in 1995 on sexual abuse charges. Members of the community previously believed he was jailed for preaching the gospel.
The Sunday TV programme reported that a total of 65 people have left the community from 2007 to 2015.
The Gloriavale Christian Community has more than 500 members and was founded in 1969. It is located at Haupiri, inland from Greymouth on the West Coast. It relocated from its original North Canterbury site in Cust (where it was known as the Springbank Christian Community) to Haupiri in 1991. The community is totally self-contained.
There is little contact with the outside world, access to media and the internet is heavily restricted, limits are placed on clothing and diets, marriages are arranged informally, and if anyone decide to leave, they are ex-communicated.
The group has had three installments of the TV2, NZ On Air-funded series; A World Apart in 2014, Life and Death in 2015 and A Woman's Place in 2016.