A coroner has made a series of recommendations following his investigation into the death of a staff member in a Waikato prison in 2010, but the Corrections Department is yet to commit to any of them.
Coroner G Matenga found several shortcomings in the procedures at Springhill Corrections Facility in the lead-up to the death of corrections officer Jason Clint Martin Palmer, 33, following an incident on Saturday, May 15, 2010.
Mr Palmer received a single punch to the head from inmate Latu Kepu, then 21, which left him unconscious as he fell and struck his head on a concrete floor.
He died in hospital the next day.
Kepu was found guilty of the manslaughter of Mr Palmer.
Mr Matenga said he was keen to properly establish the causes of death, and to find out if there was any systematic failures that could be corrected to prevent a similar death.
On the Friday before the incident, the decision was made that Kepu, who was a high security prisoner sentenced to two years and eight months for crimes involving dishonesty and violence, should be transferred to a maximum security prison.
Property belonging to another prisoner had been found in Kepu's cell.
The discovery followed a string of other incidents at Springhill.
These included Kepu swearing at staff, assaulting a staff member , activating a cell alarm and a sprinkler alarm and disfiguring property.
All were dealt with internally.
Following the theft, Mr Palmer, Kepu's case manager, consulted with his principle correction officer, and it was decided that Kepu should be charged and upgraded to maximum security, which would require him to be shifted to Paremoremo in Auckland.
The acting senior corrections officer and the unit manager were left in charge of the documentation and Kepu's transfer.
However, after calling Paremoremo on Saturday, the decision was made to transfer Kepu on the following Monday due to logistics issues.
Kepu, who was described as a big bully, disliked being kept in his cell on Saturday morning when the other inmates were released.
He also made verbal threats about Mr Palmer to another corrections officer.
These were not formally reported.
The decision was made to let Kepu out of his cell later on Saturday when his fellow inmates were in lockdown.
Mr Palmer and two other guards were all at the door of Kepu's cell when his door was opened.
Kepu quickly turned to Mr Palmer and threw the fatal punch before he was quickly locked back in his cell by the other two guards.
In his assessment of the events, Mr Matenga found five areas he felt warranted recommendations for the Corrections Department to employ.
Mr Matenga suggested they develop a clear policy around the transfer of prisoners classified or reclassified as maximum security, including keeping an accurate record.
He recommended the formal adoption of an alternative unlocking procedure for maximum security prisoners.
He said they should be temporarily held in a non-maximum security facility, and for others who were perceived to be a physical threat.
Staff would need to be trained for this.
The third recommendation was to reinforce the training of staff around the reporting and recording of threats.
He used Mr Palmer's case as an example to highlight its importance.
His fourth recommendation was to reduce the timeframe for the management plan of directed segregation prisoners to be reduced to one day.
Finally, Mr Matenga recommended a "control and restraint stance" be adopted by staff when unlocking a prisoner.
Corrections Department northern regional manager Gavin Dalziel said the department would "carefully consider" the five findings and respond to them.
"Corrections officers do a difficult job and manage some of the most challenging members of society. Their safety is of the utmost importance.
‘We are always working to improve our processes and procedures," Mr Dalziel said.
- © Fairfax NZ News
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