Ms Gell, who led a clinical review of the care provided to Jai Davis (30), said while nurses had continued to be concerned about his condition and had asked corrections officers to continue observations of him, they did not provide him with the opportunity to have further medical intervention.
"Whether he would have accepted further interventions is not known - you cannot force people to take treatment."
At a minimum a medical officer (doctor) should have been phoned for advice, she said.
She outlined changes which had been made to training and procedures. The case had been discussed with ‘' every single nurse working for us'' and the lessons learned were being applied throughout the country, she said.
She emphasised the need to take regular clinical recordings such as blood pressure, pulse rate, general observation and the state of the pupils in order to monitor the condition of a person suspected of concealing drugs.
The hearing, which enters its eighth and final day today before Otago-Southland coroner David Crerar, has been told Mr Davis was held in an at-risk unit (ARU) after being admitted to the prison on Friday February 11 because he was suspected of having illicit drugs concealed within.
The court has been told it is likely the drugs concealed, dihydrocodeine, diazepam (valium) and cannabis, were retrieved and consumed by Mr Davis.
He was found dead at about 5am on Monday, February 14.
Evidence has highlighted communication problems and a lack of training within the OCF at that time, questioned the standard of his health care, and noted the failure of staff to carry out some checks as required.
Yesterday, the section of the law used to segregate Mr Davis was the subject of questioning of Corrections Inspectorate investigator David William Roche Morrison who carried out an investigation into the death in 2011.
Counsel for the Howard League Nigel Hampton QC said a fatal flaw in the handling of Mr Davis was that he had been segregated for security and not health purposes.
Mr Hampton asked if his investigation had addressed whether section 60 of the Corrections Act should have been used which would have involved a medical officer in Mr Davis's case from the outset.
Mr Morrison said he had deemed referral to a medical officer was covered under section 58.
Mr Hampton: "It fell through, didn't it?''
Mr Morrison:" Yes, it did.''
Mr Morrison's report found observations of Mr Davis were not completed correctly or accurately, the doctor had not been called and informed about why Mr Davis was being held in the ARU, Mr Davis was not provided with required documents about his segregation, and notes were not kept of each visit by nurses and placed in his medical record.
He also found nursing staff were unfamiliar with the process and requirements of the prison manual relating to dealing with a prisoner suspected of concealing contraband internally and that some verbal instructions from nurses to corrections officers were not confirmed in writing.
He told the hearing his recommendations, on training and that prison management investigate the issues of non compliance with procedures, false recording of observations and failure to verbally arouse Mr Davis as instructed, had been accepted by Corrections.
A further recommendation that Corrections consider a protocol with the Ministry of Health to facilitate the X ray of a prisoner suspected of internally concealing contraband had not proceeded as it was considered prison services already had the ability to have such services at local hospitals.
Mr Morrison was subjected to questioning from counsel on the limited scope of his report including those from Nathan Laws, appearing for the Davis family, on whether the investigation had included any scrutiny of the justification for suspending Mr Davis's entitlement to minimum of an hour of exercise daily.
Mr Morrison said it had not. In another response he said it was possible that Mr Davis taking observed exercise in a secure yard could threaten the security of the prison. That would have been a management decision to make.
Only the executive summary of Mr Morrison's report was made available to the media yesterday, but Mr Crerar said he would release the full report today after considering concerns from Corrections counsel Mary-Jane Thomas about whether medical information about Mr Davis should be redacted. Mr Davis's mother Victoria said she had no concerns about that information being made public.
Among witness statements read to the court yesterday was one from Robert John Campbell, a corrections officer at the time of Mr Davis's death, and now living in Australia.
Mr Crerar said he would have preferred Mr Campbell to be present but did not have the power to subpoena him.
Mr Campbell said he had been on duty on the day Mr Davis came to the prison and thought he may have searched him. He had been told he was ‘'concealing''.
Later that evening he told a nurse that Mr Davis looked ‘'different from when he came in''. He noticed her was itchy all over, speaking with slurred speech and had droopy eyes.
Mr Campbell said he thought he was ‘' tripping out'' and said to the nurse ‘'he's not right, he's off his tits''.
He was told ‘'he'll be right''. He said he was annoyed and would have called an ambulance himself, but was not a medical expert so he left it to the nurse.
