A coroner has been unable to determine how a New Zealand man found hanging upside down in a drum of water at a Samoan prison died - citing several possible scenarios.
Hans Dalton travelled with his family to Samoa in December 2012. But while there they were confronted with Cyclone Evan, the worst tropical cyclone to hit the Pacific nation in 20 years.
During the natural disaster, Dalton suffered a mental health episode.
His family sought help for the 38-year-old from local authorities as he became increasingly agitated - but instead of being taken to a hospital he was moved to Tafa'igata prison because of the lack of facilities for mental health patients.
The next morning, Dalton's bruised body was found upside down in a drum of water inside a cell.
Police initially declared the death a suicide but later charged an inmate with murder. However, the conviction was overturned because of a lack of evidence.
Several unsuccessful efforts were made by New Zealand police and the coroner's office to gather evidence from the Samoan Government over Dalton's death.
His family fought for an inquest to shed light on how Dalton died.
Eventually, after Dalton's family met with Deputy Prime Minister Winston Peters in September last year, an inquest was held in December before Coroner Peter Ryan.
Today, he released his findings.
He said Dalton would be alive today if Samoa's acute in-patient facility was better and also said Dalton was not properly monitored by police when transferred to their custody - a factor that also led to his death.
While the cause of death was ruled to be drowning, Coroner Ryan has not been able to determine exactly how Dalton died.
Coroner Ryan ruled at the time of Dalton's death the Samoan mental health service's acute in-patient facility was a temporary structure, which proved incapable of confining the man in his "agitated and aggressive state".
"If this facility had been adequate for the task, the need for Mr Dalton to be transferred to prison would likely have been avoided," he said.
"While incarcerated in Tafaigata Prison, Mr Dalton was not adequately monitored by prison staff despite being obviously agitated at that time and engaging in self-harming behaviour."
Dalton was locked in a cell, and spent the night shouting, swearing and banging his head against a wall, Coroner Ryan's findings read.
Apart from the visit by mental health services staff around there is no indication he received any further mental health or medical assistance overnight.
The coroner said if Dalton had been constantly monitored it is likely his death could have been prevented.
A new mental health facility had been constructed since Dalton's death, Coroner Ryan said.
An urgent repatriation of the man when he first began to decline "would not have been a viable option because of the degree of his unwellness".
Coroner Ryan said there were several possible scenarios as to how Dalton ended up in the drum of water.
The first was that he suffered a heart attack and fell in.
The second was Dalton took his own life.
The third was that he was "upended by others" and forced in.
Coroner Ryan said that was "still a possibility and cannot be discounted".
The fourth possibility was that Dalton was trying to cope with the heat and thirst.
"On the last of those occasions, Mr Dalton may have leaned over the edge of the drum and lost his balance (possibly being semi-stunned from banging his head against the wall), thus becoming submerged head down in the drum of water," Coroner Ryan's report stated.
"With regard to the third and fourth possible scenarios, in my view the evidence for these scenarios is evenly balanced.
"Either of these scenarios is equally feasible, and there is insufficient reliable evidence to prefer one above the other.
"I am therefore unable to make a determination on the manner of Mr Dalton's death."
As part of the New Zealand request for information from Samoa, Interpol was also asked to assist.
An intervention by the Ministry of Foreign Affairs and Trade was also unsuccessful.
On the opening day of the inquest, Coroner Ryan addressed the frustrations.
"Today, six years after the death, I have received no official information from any of the Samoa authorities with very limited exceptions, the main exception being that the Samoan Ombudsman kindly provided me with a copy of a report following a commission of inquiry into the Tafa'igata prison," he said.
The 2014 prison report said Dalton's death "reflects miserably on the capacity of Samoa police to be sensitive and responsive to the situation of a mentally ill person".
Today, Coroner Ryan acknowledged the time which elapsed between Dalton's death and an inquest caused distress to his family.
"The reason for this delay is twofold. First, the fact that Mr Dalton died in Samoa presented jurisdictional difficulties and also difficulties in working out who to approach for the information necessary for my inquiry," he said.
"The Coroners Court in New Zealand has no jurisdiction in Samoa, and therefore has no power to force the Samoan authorities to provide information. There has been a lack of information from Samoan authorities, which has severely hampered my inquiry."
Second, the coroner said, the delay in completing this "very complex case demonstrates the considerable strain that the coronial service has been operating under for many years".
"Recently, the [NZ] Government increased funding for the service to allow for the appointment of a further six fulltime equivalent coroners. In my view, such a significant increase is recognition of the fact that the service has been seriously under resourced."
While Coroner Ryan said he has no jurisdiction in Samoa he would provide a copy of his findings to the Attorney-General of Samoa "in the hope that any lessons that can be learned from the distressing circumstances of Mr Dalton's death will be taken on board".
The Dalton family had also earlier requested the Coroner Ryan recuse himself on grounds of alleged bias, the Herald reported in June.
The application for recusal was dismissed and Coroner Ryan addressed it in his findings today.
"This application was made approximately seven months after the inquest had been held, and after my draft provisional finding had been completed," he said.
Dalton's family also raised concerns about a suppression order protecting the identity of a senior clinical psychiatrist who treated Dalton before the trip to Samoa.
His name remains suppressed pending an application for permanent suppression.