Samurai-sword killer Antonie Dixon had been throwing his body at cell walls and trying to choke himself in the days before his death, however, the guards in charge of him had no idea, an inquest has heard.
Earlier the inquest heard that Dixon died after strangling himself with a piece of cloth torn from an "anti-suicide" blanket in an at-risk prison cell, and had traces of methamphetamine in his blood at the time.
He had been returned to the cell just hours before from a "tie down" room where his hands and legs were restrained to prevent self-harm.
Dixon died in Auckland maximum security prison Paremoremo in 2009, a day before he was to be re-sentenced for a drug-fuelled crime spree where he maimed two women with a samurai sword, murdered James Te Aute and held another man hostage.
Detective Sergeant Richard Armstrong, who was called to the prison on February 4, the night of Dixon's death, said although there was a camera in the inmate's prison cell, no CCTV footage was available because the lens had been covered with wet toilet paper.
Armstrong said when he went into Dixon's cell he noticed spatterings of blood on the door at head height and lower, suggesting the prisoner had thrown himself at the side of his cell.
However, he could not see fresh injuries on Dixon's head.
Armstrong gave an overview of the police investigation into the death, which concluded no one else was involved.
This was partly based on the evidence of a Corrections officer at the prison, who raised the alarm at 8.53pm after seeing Dixon with blood on his face and a ligature around his neck while he was conducting 15-minute checks.
The officer called for help but had to wait for three other officers to arrive before he could enter the cell because prison policy required it.
After entering the cell, about five minutes after first seeing Dixon in trouble, a nurse removed the ligature and CPR was performed on Dixon.
An ambulance arrived at 9.20pm and CPR was further attempted before Dixon was pronounced dead.
Medical reports showed that as well as the compression injuries to his neck, Dixon had several bruises and abrasions, and a laceration - but none of which contributed to his death.
There was a suggestion from a specialist in emergency medicine that if the officers had removed the ligature earlier, Dixon "might" have been saved.
Strangulation caused death within four or five minutes, the report said.
Armstrong also gave evidence from and ESR report that there was acetate and small amounts of methamphetamine in Dixon's blood and urine when he died - the acetate suggesting Dixon had been starving himself. The methamphetamine was consistent with some recreational use.
Coroner Garry Evans asked the guard, whose name is suppressed, if he was aware that Dixon had been throwing himself at walls and trying to kill himself while at Mt Eden prison just days before.
The officer said he was not.
Evans also questioned the guard over why he had not removed the toilet paper from the camera in Dixon's cell, which he'd put there before he died. The guard said it was too dangerous to go in the cell alone.
Evans asked if the cameras were being monitored when Dixon died. The officer did not know.
"[So] he was tearing up a blanket without any knowledge on your part? And that's what he used to strangle himself. But you didn't observe that did you?" Evans said.
The officer said no.
Evans asked if he had, would he have entered the cell under the "critical incident" provisions which allowed officers to ignore their prisoner/guard ratio and enter the cell to safe a life, "instead of waiting for four others?"
The officer replied he would not have ignored the management plan for the prisoner. He was not aware of the provisions mentioned by the coroner.
Earlier today, Dixon's brother Julian complained to Evans that he was unaware the hearing would be public.
He said now-retired coroner Murray Jamieson had promised him the hearing could be in private, so he was unprepared for media to be present.
"I hadn't expected anything that happened here today. I believe I've been misled," Dixon said.
After retiring to consider the argument, Evans ruled that because Dixon died in custody, it would be contrary to the law not to hold a public inquest. He did not accept that the Dixon family were told the hearing would be held in private, or that they were misled.
The inquest continues.
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