Concerns about water colour and substandard conditions raised by rioting prisoners who destroyed the top jail at Waikere Prison were flagged in an Ombudsman's report last year.
Yesterday, the 16 prisoners who ran rampant on the jail's roof for nearly a week surrendered.
The drama started when prisoners lit several fires in the exercise yard ultimately forcing the evacuation of the top jail.
During the six-day stand-off, the rioters continued to light fires and threw debris at staff responding to the crisis.
Advocates repeated throughout the saga that the men were protesting against poor, unhygienic and dehumanising conditions.
Corrections Minister Kelvin Davis denied that prison conditions were the reason for the unrest.
The prison - now ravaged by the devastating riot fires - opened in 1911 near Te Awamutu in the central North Island.
After an unannounced inspection of the facility in late 2019, Chief Ombudsman Peter Boshier published findings in August that said conditions "significantly varied" between the high and low security complexes.
Those in the high security complex (HSC) were double-bunked in cells "originally designed for one" with poor living conditions. Limited actitives were provided to them.
"In contrast, the low security complex (LSC) was spacious, clean, tidy and outdoor areas well maintained."
However, the supply and quality of clothing and bedding was "problematic" across both complexes.
Inspectors found stained, lumpy pillows, torn mattress covers and thin duvet inners.
In response to a survey, 68 per cent said they usually got clean sheets weekly however 52 per cent said they were not offered enough clean and suitable clothes.
A "significant number" of men expressed concern about water quality, describing it as "dirty and cloudy".
Inspectors noted water colour varied in several LSC units.
"They raised the issue of water quality and safety with senior managers at the time of the inspection, and were advised the water quality was regularly tested."
Separates Units were deemed "no longer fit for purpose, compounded by the lack of natural light, poor ventilation and small cell sizes".
Violence was rife inside the prison and accounted for 22 per cent of all incidents over a year.
The prison had the second highest gang population (44 per cent including affiliates) in the country.
Health services were good, especially for older men and transgender detainees.
"The relationship between custodial and health services staff was positive and constructive."
A dedicated facility for those at risk of suicide or self-harm or subject to medical oversight had "strong leadership". It showed commitment to improving the experience of those in their care, the report said.
A not-fit-for-purpose HSC environment was impacting adversely on the prisoners, presenting the leadership team with "significant challenges".
"I am aware a new 600-bed facility is under construction at the Waikeria Prison site. I am told the new prison will include a 100-bed mental health facility co-designed and co-run between the Department and the Waikato District Health Board."
Boshier welcomed this development, due to open next year.
The report provided many more insights and can be in full here.
Spotlight on High Security Complex
The HSC cells were described in the report as being in a poor state, poorly ventilated and uncomfortably hot.
Double-bunking meant cells were "unacceptably cramped" and the person in the lower bunk was unable to sit upright.
Meals, apart from lunch, were delivered to the cells because of the yard-to-cell regime. This meant prisoners were eating meals near an uncovered toilet.
"Tāne having to eat in such close proximity to the toilet is, in my opinion, both unsanitary and culturally inappropriate."
This arrangement did not align with the Department's Hōkai Rangi strategy relating to the development of minimum "Manaaki Standards".
In HSC men were making noodles and hot drinks using water from the yard shower.
Inspectors were told they could not access hot water because of the security risks associated with high security prisoners.
Former prison officer Keith Smith, a Labour Party supporter, said there was a "massive" difference between the high security and low security complexes.
"The conditions in that top jail are sub-human."
Comments about hot, poorly ventilated, cramped conditions were bang on, he said.
"How some of those prisoners survive in the height of summer defies logic."
Smith said the water had been a problem from day one during the decade he worked there.
There was seasonal variation and sometimes the water was worse than brown, he said.
Smith, who retired over a year ago, said safety of staff had always been his primary concern, followed by safety of prisoners.
"Anybody with an ounce of common sense knew that if a fire got a hold of that place it was a goner."
He believed the finger needed to be squarely pointed at the politicians, from both sides, for the state of Waikeria Prison.
"I'm frightened that some poor bloody staff member is going to wear the brunt of blame for whatever happened out there."
However, he said he applauded Labour's "courage" in trying to go in a new direction and felt there was no way Waikeria could be fixed in three years.
At the press conference that followed the surrender, Department of Corrections chief executive Jeremy Lightfoot said there was no excuse for the men's actions.
He fronted the many allegations and said Corrections was not aware of the 16 men raising complaints.
"The prison is in a rural location. Water comes from a bore and a through a treatment plant. The water is tested six days a week and there have been no concerns with the safety of the water."
Since the Ombudsman's inspection, a number of steps had been taken to improve conditions in the top jail, including maintenance and repainting, he said.
Yards are checked daily for damage and fixed as needed with anti-graffiti paint used, he said.
An inspectorate visit in January last year confirmed "significant gains" had been made with managing clothing provisions.
Corrections had already acknowleged the top jail had reached the end of its ability to be used without requiring significant investment, he said.
There were ongoing issues with prisoners damaging clothing, towels and bedding, he said.
About $10,000 is spent per month on replacement items at Waikeria.
A double order of the items was made in November and December last year, he said.
Māori Party co-leader Rawiri Waititi announced the surrender yesterday in a statement about 1pm.
Waititi, the MP for Waiariki, said when injustice was normalised, defiance and protest is necessary.
"These men are not animals, they are humans; they are brothers, fathers and sons and are deserving of better treatment."
Then Davis finally broke his silence, after staying mum on the subject during the stand-off and drawing criticism.
His statement confirmed most of the prisoners involved were members of the Mongols and Comancheros gangs.
Five of the men are deportees from Australia, with three subject to returning offender orders because of their criminal convictions.
Davis said the reckless arson, violence and destruction carried out by these men put others in danger.
He said they could have used legitimate avenues to raise their concerns.
Corrections would be undertaking a comprehensive review of how the situation was able to escalate and would also assess the damage left behind.
However, no one is expected to return to the top jail.
Davis also claimed political attention given to them had "emboldened them" and increased risk to safety.