Antonie Dixon was never going to attract sympathy. Wild-eyed with a long list of convictions, the man known as the "samurai sword killer" was more likely to engender anger than empathy from the public - many of whom believed he was faking madness to escape jail.
Dixon was jailed in 2005 for the murder of James Te Aute, who he gunned down during a P-fuelled crime spree that also included maiming two women with a sword.
Defence lawyer Barry Hart argued Dixon was insane, but the jury found otherwise and the 40-year-old got life.
But when Dixon allegedly killed himself in 2009, two questions arose. Was he mentally disturbed, and, if so, why wasn't he in care?
A coroner's hearing this week may answer those questions, but prison reform advocates say, no matter what, something has to be done for the hundreds of other mentally ill inmates.
Since 2008, 75 people have died in prison, where the suicide rate is 11 times higher than in the general population. The coroner investigated 37 of those deaths, recording 13 as suicide, a trend the ombudsman called a "serious concern" in a 2011 report, recommending responsibility for healthcare should be removed from Corrections. "The situation whereby custodial staff have to manage prisoners who, by any layperson's measure, are grossly disturbed, is unsatisfactory for prisoners and staff."
That report came after criticism from, among others, the auditor general, the National Health Committee and the Human Rights Commission, and numerous recommendations from various coroners.
Wellington's Howard League for Penal Reform completed a study into 12 prison suicides since 2008 and reported health services were underfunded and under resourced. "New Zealand is supposed to be a civilised Western democracy, but these figures are a disgrace," spokesman Roger Brooking said. "It's often said that you can judge a society by the way it treats the most vulnerable. I wouldn't like to judge New Zealand based on this."
Among concerns raised have been access to healthcare, long waiting lists for patients who need to go into psychiatric facilities, poorly-trained staff, a lack of mental health screening, and the use of at-risk units for suicidal inmates.
Corrections said providing care within a prison presented unique challenges. "The physical environment and the need to maintain security are significant factors managed through robust systems and effective communication between health and custodial staff," acting national health manager Bronwyn Donaldson said.
A number of concerns raised had been addressed by introducing new screening that increases Corrections' ability to detect mild or moderate mental illness at an early stage. The department had also introduced a review of all at-risk clothing and bedding.
Victoria University criminologist Dr Elizabeth Stanley said not all the blame could be put on Corrections. "Part of the problem is that people are being sent to prison who shouldn't be. And there are a lot of people who, while they've offended, are victims too. We don't address that."
The hearing into Dixon's death opens tomorrow.
- Sunday Star Times