A coroner has called for improved assessment and monitoring of prisoners after two suicides at Rimutaka Prison.
Garry Evans today released his findings into the deaths of Peter William Bean, 35, in October 2004, and Barney Maxwell Cassidy, 39, in March the same year.
Mr Bean was serving a five-yearsentence for violence and drug offences and was taking medication for depression at the time he died.
A report showed he was transferred from Manawatu Prison to Rimutaka in February and his medication dose was not reviewed as recommended by a medical officer.
An appointment with a health officer set for October 5 was missed for unknown reasons and rescheduled for October 12, but Mr Bean died four days earlier.
Mr Evans said it was clear the health needs of Mr Bean were not properly met.
He recommended steps be taken to ensure the physical and mental health of inmates be subject to review as soon as practicable when health professionals decided it was necessary.
Mr Cassidy had been arrested for domestic violence on March 21 and was being held in Rimutaka Prison awaiting a court appearance when he was found dead two days later.
Investigations showed discrepancies in Mr Cassidy's general assessments, which were partially to establish whether or not he was a suicide risk.
The case prompted Mr Evans to urge a more proactive approach in the assessment of new arrivals, and more interaction with prisoners.
