Coroner finds Corrections missed risk assessment before Invercargill inmate Nukuroa Strange's death
A Coroner has recommended changes to the way Corrections manages vulnerable prisoners as a result of the death of an Invercargill Prison inmate.
Nukuroa "Nuku" Strange, 30, died in his cell on August 4, 2022 after he was shifted out of a unit for at-risk prisoners and segregated.
Strange, who was on remand, learned he was facing a prison sentence of about eight years for 22 driving, property and firearm offences.
His partner had ended their relationship because of his likely long jail term.
In findings released on Tuesday following an inquest, Coroner Amelia Steel said Strange had attempted suicide twice since June 2022, and Corrections staff deemed him at risk of self-harm four times.
The day before his death, Strange was shifted out of the prison's Intervention and Support Unit (ISU) - special rooms allowing for close monitoring and access to specialist care - after being deemed "no risk" of suicide.
Corrections staff then put him on directed segregation, meaning he was to be kept isolated from other prisoners without any visits.
Steel found staff skipped a mandatory face-to-face risk assessment when segregating Strange, instead relying on the "no risk" assessment.
"While it is not possible to state whether an in-person review risk assessment would have altered the outcome for Nuku following his directed segregation, it represents a missed opportunity to reassess acute risk when it was formally required," she said.
Expert evidence at the inquest noted a vulnerable prisoner with plans to self-harm might say "all the right things" to staff simply to secure a transfer from ISU to standard cells where they had more privacy.
Strange had initially objected to moving to the ISU, in one instance hitting an officer with a piece of wood.
His resistance twice resulted in "planned use of force", including pepper spray, and was the reason for his segregation, the report said.
The Coroner said Strange had a long history of mental health and psychosocial vulnerability.
He had previously been incarcerated on 11 other occasions and received four sentences of imprisonment.
Visibly distressed before death
On the morning of his death, two other prisoners warned staff about Strange's behaviour.
One said they had seen him "visibly distressed" on the phone, while the other warned Strange was not well enough to be in the South Unit and said he should return to the ISU.
Strange's last phone conversations that morning were to his ex-partner and to his mother.
"He told his mother he loved her and she told him not to do anything stupid. Footage from South Unit CCTV was played during the inquest and Nuku could be seen leaving those conversations, wiping his eyes," the report said.
Strange was visited by a staff member after the phone call who said he "did not appear agitated".
He was found dead at 11.03am by a fellow prisoner cleaning cell windows, 25 minutes after his cell was locked.
New transitional units, more mental health staff recommended
Steel made five key recommendations, including the creation of new transitional units for prisoners shifting between the ISU and prison units.
"These units would extend current focus beyond the 'acute' risk and would strengthen the support available to prisoners experiencing distress," she said.
She also recommended changes to the way Corrections carries out risk assessments, saying health and medical staff should be consulted and any historical self-harm alerts should remain active on prisoners' files indefinitely.
"This reflects the unpredictability of suicide risk and its manifestation; it may assist to remove bias associated with completing the assessment may support staff to complete the assessment correctly and in accordance with policy; and it mitigates an overreliance on the prisoner's self-reporting of risk," she said.
Steel said Corrections should employ more trained mental health staff and provide more frequent training focused on suicide risk for existing custodial and health staff.
Steel said Corrections failed to act with urgency to eliminate known hazards in cells, despite being warned of the risks after a similar death in 2016.
She described the current programme as "disparate and underfunded".
Corrections responds
Following Strange's death, Corrections said it had introduced daily multi-disciplinary team meetings between custodial and mental health staff to share clinical and observational data about inmates.
All high-risk prisoners had active care and management plans, it said.
Corrections said it had also made risk assessment forms more detailed and made the presence of health staff mandatory during any planned use of force.
In response to the Coroner's recommendations, Corrections agreed to continue investigating opportunities for staff suicide training and update alert systems to ensure historical self-harm risks were kept active on files.
Corrections said it was not feasible to consult health staff on all risk assessments but it would look to mandate it in "defined, high-risk" situations, such as any recent self-harm or suicide attempts or recent placements in the ISU.
In response to the recommendation for new transitional units, Corrections said it was "restricted by available funding and budget allocations", and such a move could have unintended consequences.
"A step-down unit could still be quite isolating, or could promote socialisation with other vulnerable at-risk people," it said.
Corrections said it had taken steps to create a more therapeutic environment in the mainstream unit and the ISU, including more rehabilitation programmes, new paint and decorations and new furniture.
Invercargill Prison was recruiting more mental health nurses and counsellors, Corrections said.
Where to get help:
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason
- Lifeline: 0800 543 354 or text HELP to 4357
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends
- Depression Helpline: 0800 111 757 or text 4202
- Samaritans: 0800 726 666
- Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz
- What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds
- Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, and English.
- Victim Support 0800 842 846.
- Rural Support Trust Helpline: 0800 787 254
- Healthline: 0800 611 116
- Rainbow Youth: (09) 376 4155
- OUTLine: 0800 688 5463
- Aoake te Rā bereaved by suicide service: or call 0800 000 053
If it is an emergency and you feel like you or someone else is at risk, call 111.