That comment was made by Corrections chief custodial officer Neil Beales in a report into circumstances surrounding the death of the remand prisoner, Jai Davis (30), at the Milburn facility, on February 14, 2011.
A Coroner's Court hearing, which ended in Dunedin this week, was told OCF intelligence officers had recorded telephone conversations involving Mr Davis that made it clear he planned to take ''candy'' (slang for prescription drugs) into the prison.
Mr Davis died of a drug overdose at the prison not long after he smuggled in drugs in February 2011.
The Beales report, released to the ODT yesterday, highlighted extensive issues with communication, and other matters, including training, which have become evident since the death of Mr Davis.
Mr Beales wrote that OCF management knew Mr Davis might be concealing ''weed'' and ''candy'' but ''that information was not provided to all staff that were managing Mr Davis'' in the prison's at risk unit (ARU).
This meant some staff were managing him ''without a comprehensive understanding of the risks Mr Davis was facing''.
''It would have been prudent for OCF management to have spoken to the health centre manager or the medical officer when making a decision about how to manage Mr Davis.''
This ''omission'' had been compounded by the decision to use section 58 of the relevant legislation as opposed to section 60, involving ''segregation for medical oversight'', which would have included referral to the health centre manager/medical officer.
The lack of a ''considered and communicated plan'' about how Mr Davis was to be managed meant that key staff were ''sometimes ineffective in their roles because they did not have all the information'' about what risks were being managed for him, and why.
What was often a primarily security-based focus in prison needed to be ''balanced with the health needs and wellbeing of prisoners''.
After receiving intelligence information, OCF management had been ''correct to mitigate the security risk'' and to ensure that contraband drugs ''did not come into the general prison population''.
The use of contraband drugs in prison made ''the environment very unsafe for prisoners and staff'' and such drugs led to ''increased violence, gang tensions and criminal activity'', the report said.
But there should have been ''greater awareness of risks'' to Mr Davis himself.
Four recommendations arising from the report had been accepted and were being implemented this year:
• To ensure ARU custodial staff understand how to manage prisoners under dry cell conditions and ''how to escalate any concerns appropriately''.
• To ensure ARU staff understand the requirements and expectations for carrying out and recording observations of prisoners held in the ARU and that all managers and supervisors regularly visit and check logbook entries to monitor staff carrying out observations.
• To amend the prison operations manual so the policy regarding internal concealment is located under the movements (at-risk) section.
• To develop practice guidance about dry cell prison procedures to ensure a consistent practice is followed at all prisons.
