Prison officers were justified in restraining an inmate after a struggle described as a "seething mass of humanity", a coroner's inquest has found.

A combination of asphyxia and morbid obesity was responsible for the death of Nicholas Ward Harris, 36, who died while being restrained in his Waikeria Prison cell early last year.

Harris died while being restrained in a prone position on the floor of his prison cell by a number of Corrections Officers at Waikeria prison, in the Waikato, on January 9, 2011.

In his findings, released today, Coroner Peter Ryan said the officers used "justifiable and necessary restraint", carried out in accordance with safety guidelines.


Harris had been arrested the previous week on a number of charges and was being held on remand at the time of his death.

At about 11.05am on the morning of January 9, a staff member issued a "code blue" when CCTV footage showed signs Harris was about to harm himself.

Staff were instructed not to enter the cell unless it was obvious Harris was hurting himself and the situation was diffused when he handed over some of the items he had ripped up.

However, shortly afterwards, he threatened to harm himself again and officers entered the cell with the intention to relocate him.

Harris resisted strenuously, the report said.

"Six officers entered the cell, and immediately attempted to apply control and restraint techniques on Mr Harris as he lay face down on the cell floor.

"Mr Harris violently resisted the application of these holds, and additional officers were called to assist."

Following a struggle that lasted about five minutes, Harris was finally restrained and handcuffed.

It was at this point that he stopped resisting.

When a nurse outside the cell could not find any signs Harris was breathing, an ambulance was called but Harris could not be resuscitated.

The coroner found that the cause of death was "asphyxia of an undetermined cause, initiated either by self-strangulation or pre-existing medical condition, but in combination with restraint, with an underlying condition of morbid obesity with secondary dilated cardiomyopathy".

While the weight of the officers on Harris' back contributed to the asphyxia that killed him, they were "clearly aware" of the risks and made attempts to alleviate it during the struggle, which the coroner described as a "seething mass of humanity".

It was noted that his ability to breathe was also compromised by his obesity and lying prone.

Mr Ryan said that it was clear that Harris' attitude and behaviour towards the Corrections officers had been major contributing factors in his death.

This behaviour had "necessitated a robust spontaneous control and restraint process".

"I am satisfied from the evidence before me that this death occurred during a justifiable and necessary restraint of an aggressive, threatening and struggling prisoner, and that the restraint was carried out in accordance with the guidelines covering restraint procedures," the coroner said.

Mr Ryan also concluded that Harris' poor state of cardiac health and his morbid obesity played a part in his death.

"It is likely that these underlying medical conditions made Mr Harris more susceptible to the effects of oxygen restriction."