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A former senior Corrections officer says cameras in the special needs unit inside Mt Eden prison were broken or faulty when a prisoner was found unresponsive in his cell.
Kody Gunson died on October 5, 2015, as a result of a suspected suicide.
Coroner Alison Mills is holding an inquest into his death at the Auckland District Court.
The inquest heard Gunson had been remanded in custody after an initial court appearance on October 3, two days before his death.
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The 21-year-old had complained of being attacked by someone wielding a baseball bat. He said he had been hit in the head and elbow.
Mt Eden prison was being staffed by private prison operator Serco employees at the time, although the management of the prison had been taken over by Corrections, following allegations of “fight clubs”.
David Kereti was a senior Corrections officer at the time and was on secondment from Whangaui Prison.
He told the inquest many of the inmates in the special needs unit had mental health issues but the unit itself was “really strange”.
He said at-risk patients were allowed their own clothing with normal mattresses, instead of being given non-rip gowns and mattresses.
“Some of the cameras were faulty. Some of the cameras were broken.”
The broken cameras meant at-risk prisoners could only be put in cells where cameras were working and the unit was under-staffed.
“The worst thing was staff knew about it but no one wanted to do anything.”
Kereti said he allowed Gunson to make a private phone call to his family because he thought that would help him.
He said after the phone call Gunson was upset and it wasn’t until later that Kereti learned the phone call had involved a relationship break-up.
“For me that would cause alarm bells to ring.”
Kereti said a risk assessment should have been carried out afterwards but was not.
Simon Mount KC, the lawyer assisting the coroner, asked about reports from another Corrections officer that Gunson was “hearing voices … telling him to do bad things”.
Kereti said he heard “absolutely nothing” of those reports.
He spoke of the filing system in the special needs unit as being “horrendous” and said he made wide-spread changes in the unit before he left.
Earlier the inquest heard from Corrections officer Ronaldo Frast who was the receiving officer on the day Gunson arrived at Mt Eden prison.
“He said he had been hit by someone with a baseball bat … he said he had been accused of interfering with a car.”
Frast said Gunson was initially angry about being in prison but soon calmed down.
He said he could not recall if he saw an alert on Gunson’s file that flagged an earlier suicide attempt in custody only months before.
Regardless, Frast placed Gunson in the at-risk unit, on account of his physical injuries, not mental health concerns.
“I asked the nurse… this fella is not looking right.”
Frast said he flagged with management that Gunson should be taken to hospital.
He said Gunson was on 15-minute observations, meaning a prison officer would check on him in his cell every 15 minutes.
Under cross-examination from Gunson family lawyer Tony Ellis, Frast confirmed he had to help Gunson get his T-shirt on, due to the injury to his arm.
Frast also confirmed Gunson was coughing “a ridiculous amount” and was gagging.
Abigail Dougherty/Stuff
Kody Gunson was put in a special needs unit and was meant to be observed every 15 minutes by Corrections officers.
He said Gunson was put in a “camera cell”. Asked if the cameras were working, Frast said he had “no knowledge of that”.
Frast said he expected the 15-minute observations to be carried out but described it as “a bit of a marathon” and required officers to run between two floors of the prison to cover two units.
The nurse on duty at the time, who has interim name suppression, said she too noticed Gunson was trying to vomit. She also saw a contusion on his head and thought he should go to hospital.
She told the inquest she had to assess 16 prisoners on the day and noted Gunson had a previous suicide attempt while in custody but was not reporting risks of any self-harm.
The nurse said neither she nor her colleague had time to check on Gunson after he returned to the prison from hospital at 2am on October 4.
She confirmed to Ellis that the nurse staffing levels at the time were inadequate.
The nurse was also on duty that evening when a medical emergency alert was sounded at about 6.45pm.
Gunson was found in his cell with no pulse and was unresponsive.
She and a prison officer responded with a medical kit that included an oxygen bottle. She was asked if the oxygen bottle had oxygen in it but said she could not now remember.
The nurse said the medical bag was meant to be regularly checked but she did not know if it had been checked.
“During this time we had a severe staff shortage,” the nurse said.
“Right now, under the Department of Corrections, we have five to six nurses to do the meds alone.”
She said there were now also additional clinical nurses.
Coroner Mills asked if the inmate population in 2015 was comparable.
“It’s about the same number, ma’am.”
Asked about her and the prison officer’s efforts to resuscitate Gunson, she answered: ”We did the best that we could, ma’am”.
Asked what could be learnt, the nurse said: “It is very important we have adequate [numbers of] staff.”
The inquest continues.
Where to get help
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1737, Need to talk? Free call or text 1737 to talk to a trained counsellor.
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Anxiety New Zealand 0800 ANXIETY (0800 269 4389)
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Depression.org.nz 0800 111 757 or text 4202
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Lifeline 0800 543 354
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Mental Health Foundation 09 623 4812, click here to access its free resource and information service.
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Rural Support Trust 0800 787 254
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Samaritans 0800 726 666
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Suicide Crisis Helpline 0508 828 865 (0508 TAUTOKO)
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Yellow Brick Road 0800 732 825
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thelowdown.co.nz Web chat, email chat or free text 5626
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What’s Up 0800 942 8787 (for 5 to 18-year-olds). Phone counselling available Monday-Friday, noon-11pm and weekends, 3pm-11pm. Online chat is available 3pm-10pm daily.
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Youthline 0800 376 633, free text 234, email talk@youthline.co.nz, or find online chat and other support options here.
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If it is an emergency, click here to find the number for your local crisis assessment team.
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In a life-threatening situation, call 111.
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