A dysfunctional and uncaring culture at the Otago Corrections Facility meant Jai Davis' death went unnoticed for more than five hours after he became unconscious from a drug overdose, Coroner David Crerar has found.
In his findings, released yesterday, into the death of Mr Davis (30), Mr Crerar condemned the lack of communication between Corrections staff and the ''self-serving'' misinformation they provided to authorities after the death.
He also criticised police for their ''cursory'' and ''flawed'' initial investigation into the death, which hindered his inquiry into the matter.
Mr Davis was a remand prisoner at the Milburn facility when he died overnight on February 13, 2011, as a result of an overdose of codeine and valium pills he attempted to smuggle internally into the jail.
Late last year, more than 40 witnesses gave evidence and 235 exhibits were produced at the inquest into Mr Davis' death.
A further 14 witnesses provided written depositions.
Mr Davis, who was the subject of an arrest warrant, presented himself to Dunedin police on February 11, 2011.
He was carrying about 30 codeine and about 30 valium tablets as well as a quantity of cannabis in his rectum, with the intent and smuggling them into jail for his associates in the Mongrel Mob.
Corrections intercepted phone calls made from the prison to Mr Davis and were aware of his intention to bring drugs into the facility.
As a result, he was kept in a dry cell from the time of his arrival at the facility to prevent his interaction with other prisoners, or attempts to dispose of the drugs.
He denied concealing drugs when questioned by Corrections staff.
However, when his condition deteriorated, Corrections staff failed to call a doctor or ambulance. One Corrections officer observed Mr Davis appeared ''grey-coloured'', was scratching and had sunken eyes.
''His breath also smelt like faeces to me,'' Corrections officer Steven Gillan observed.
Mr Crerar found acting prison manager Ann-Maree Matenga was ''poorly trained to perform her role'' and ''showed a poor appreciation of such responsibilities''.
Some of her lack of knowledge in the role was ''astonishing'', he said. Some Corrections officers had an attitude ''that effectively, `the health of a prisoner was not their responsibility'.''
Corrections management had suffered from ''buck fever'' - ''the emotion which often overcomes a hunter when a game animal appears in the rifle sights'' - in dealing with Mr Davis, he said.
''It is well established that `buck fever' creates a focus which excludes other, probably more relevant, considerations. Corrections management were so focused on the apprehension of Jai Davis that there was a general failure by Corrections management to consider other relevant implications - particularly the safety and health of Jai Davis, during his admission.''
The officers who observed Mr Davis on the night of his death ''neglected'' to provide care for him.
Corrections officers Brent Thurlow and Fred Matenga did not perform the duties they were told to.
''Thurlow recorded `observations', even though he did not attend the dry cell to make these observations,'' Mr Crerar said.
''Fred Matenga said that he saw movement by Jai Davis. Dr [Martin] Sage considers this to have been unlikely in the extreme.
''This evidence by Fred Matenga is self-serving and does him no credit. If Fred Matenga had performed `rousing obs', as he had been instructed to do, there is a probability that Jai Davis would not have died.''
Detective Senior Sergeant Colin Blackie, who investigated the death in 2013, felt there was a dysfunctionality in the prison.
However, this investigation and an earlier one did not find any criminal wrongdoing or negligence on behalf of those charged with Mr Davis' care.
Mr Crerar criticised the time it took for police to investigate the death appropriately.
''The initial investigation into the death of Jai Davis by the police was not conducted in a timely manner,'' he said.
''Too often during the inquest hearing, a witness would state that they could not recall a specific because the death was 'so long ago'.
''My inquiry has been hindered by the failure of the police to conduct the necessary (and prompt) inquiries into a death as they are required to do.''
Despite his criticisms, Mr Crerar said Mr Davis was the ''person most responsible for the circumstances which led to his death'' and there was no evidence he had the intention of taking his own life.
He recommended the Independent Police Conduct Authority (IPCA) investigate police handling of the case and the Health and Disability Commissioner investigate the circumstances of Mr Davis' death.
Police investigated the actions of officers involved in Mr Davis' handling and death.
The IPCA reviewed that investigation and found the issues identified during the inquest were ''fully considered'' during the police investigation, and the IPCA did not consider there was a need for a new inquiry.
Mr Crerar said many lessons were learned because of the death.
Health and Disability Commissioner Anthony Hill said he would wait until he had considered the full report before deciding whether further action was appropriate.
Southern police acknowledged the findings of the coroner and said Mr Davis' death led to change in the relationship with Corrections.
A police spokesman said the coroner's report had not changed the police's stance that evidence available at present was insufficient for police to investigate any individuals over the incident.
Department of Corrections chief custodial officer Neil Banks said Corrections acknowledged the coroner's findings and Corrections implemented a range of changes to improve ''practice in the management of prisoners who conceal drugs internally''.
The recommendations
• The Independent Police Conduct Authority should investigate the role of police in relation to Mr Davis' death.
• The Health and Disability Commissioner should investigate the death.
• Corrections consider adopting similar procedures and protocols as those used by police when dealing with people suspected of carrying drugs by internal concealment.
• Police consider the establishment of a generic email address for its intelligence operations so intelligence advice provided is not delayed by the non-availability of an individual email address.
