Closed circuit television records, which showed a man who died in the Otago Corrections Facility had not moved for seven hours before concerns were raised, made it difficult to accept the validity of a prison officer's statement on the matter, the Dunedin Coroner's Court heard yesterday.
Forensic pathologist Dr Martin Sage told the fifth day of the hearing into the death of Jai Davis (30) it was likely Mr Davis died some time between 10pm on February 13 and 1am the next morning.
His evidence said there was obvious inconsistency between those first examining Mr Davis' body and recorded observations made by corrections officer Peraro Frederick Matenga (Fred) who was responsible for carrying out 15-minute observations of Mr Davis in an-at risk unit (ARU).
Mr Davis had been placed in the unit because he was suspected of having drugs concealed within his body.
A suppression order on Mr Matenga's name was lifted yesterday after the failure of an appeal to the High Court against an earlier refusal by Otago-Southland coroner David Crerar to grant suppression.
Mr Matenga on Thursday refused to give evidence on the grounds it might incriminate him.
He told Mr Crerar he understood that by taking this stand it would allow the coroner to make adverse comments about his failure to co-operate with the inquiry.
Mr Crerar yesterday released statements Mr Matenga made to the police and the prison inspectorate on the matter.
In those statements, Mr Matenga said he viewed Mr Davis at 10.52 the night before he was found dead and he was "on his side and snoring".
He said when he was conducting his 15-minute observations "at times I heard him snoring when I opened up the flap".
At 3.37 am he said he saw movement under the blankets -- "a twitch of his body".
Dr Sage, in his evidence, said in the absence of corroborative evidence from the CCTV footage it was difficult to see this as valid.
There was also an obvious inconsistency between the observations recorded by Mr Matenga and the conclusions drawn by those first examining the body, which had included that rigor mortis had set in and the body was cold to the touch.
During cross-examination of Dr Sage, there was discussion about the effectiveness of shaking someone awake every 15 minutes to check their health was not deteriorating.
Dr Sage said the system was stuck between "a rock and a hard place" in a balancing act between managing the risk to the person for their own good and imposing what might be considered "draconian regimes" a civilised society might frown on.
Mr Crerar sought submissions from counsel for Mr Davis family, Nathan Laws, and from Howard Prison Reform League Nigel Hampton QC on the ethics of this question.
He may also receive advice from the University of Otago' s bioethics centre.
A support person for Mr Davis' mother Victoria Davis, Peter Miller, told the court she regarded carrying out such observations as a "no-brainer" which would mean she would "still have a son".
Ms Davis considers prison staff failed in the duty of care to her son and let her son die in the at risk unit with no medical help. She began a campaign to get what she says is justice for her son.
Pathologist Dr Alexander George Dempster told the court Mr Davis's death was consistent with the cerebral depressant effects of dihydrocodeine and diazepam (valium). The level of the diazepam was a consistent with therapeutic use.
Consulting psychiatrist Prof Paul Glue said it was possible to address the respiratory depression caused by opoids by administering an antidote naloxene.
He pointed out the relevance of the timing of this and the need for access to intensive care facilities if intervention was delayed.
Earlier in the day, the court heard from Sergeant Trevor Thomson, who outlined the early police involvement on the day of Mr Davis's death.
The prison's health centre manager Jill Thomson outlined changes which had been made to procedures and policies following Mr Davis's death.
She told the court if she had been present and aware of the situation around Mr Davis's arrival and that he was suspected of having concealed drugs within his body she would have made sure she contacted a medical officer for advice.
She said she could not recall where she was on the day Mr Davis arrived at the prison.
She would not comment specifically on the actions of the nurses on duty at the time of Mr Davis's stay.
The hearing continues.
