A prisoner died after his family's concerns over his state of mental health went ignored by prison officials, a coroner has found.

In notes found in his cell, Richard John Barriball, 42, of Milton, described himself as a "Druged up paranoid scitzofrenic [sic]. This is paranoia, self lothing and every smile is a fake until I can get away from myself again."

On October 9, 2010, Barriball was found dead in his cell in conditions indicative of suicide.

He was on remand at the time of his death.

Coroner David Crerar released his findings into Barriball's death today. In them he was highly critical of Otago Corrections Facility (OCF) staff.

"The causes of the death and the circumstances of the death of Richard Barriball have shown suboptimal care by OCF in two respects."

One was the failure of OCF to provide delivery of prescribed pain relief at a time deemed most appropriate by clinicians".

He also said two communications were made by family and by the prison chaplaincy, expressing concerns to OCF about the mental state of Barriball.

"This intelligence was not collected, recorded, reported or acted upon."

In the days leading up to Barriball's death, Crerar said the stressors faced by Barriball, "in his mind at least", were overwhelming.

"Richard Barriball considered that he was 'set up' in respect of the charges he was facing. The term of imprisonment he expected was uncertain. He also suffered from an underlying fear that he would be the victim of a prison assault."

A recent operation on his arm, which saw one of his arms in a sling, was also placing Barriball in a considerable amount of pain which he had not been given prescribed painkillers for.

Tests showed Barriball had smoked cannabis in the hours prior to his death.

"The fact that Richard Barriball had consumed cannabis, probably in the period immediately prior to his death, and almost certainly since his admission to OCF remains of concern," Crerar said.

- © Fairfax NZ News