OFFICE OF THE INSPECTORATE Te Tari Tirohia

27 August 2026

The following article appeared in issue 13 of the Prison Oversight and Human Rights Review, which focused on deaths in custody. The full publication can be found here

By Janis Adair, Chief Inspector

Mā te titiro me te whakarongo ka puta mai te māramatanga
By looking and listening, we will gain insight

Background

New Zealand has a population of around 5.36 million and, as of 2 July 2026, the prison population was 11,190 people in 18 prisons. Māori (New Zealand’s indigenous people) are over-represented, comprising around 52% of the prison population, compared with 17.5% of the general population (Statistics NZ, June 2025). Seventeen of the 18 prisons are public, three of which are for women, and one men’s prison is privately operated.

The Office of the Inspectorate Te Tari Tirohia is a critical part of the independent oversight of the New Zealand Corrections system and operates under the Corrections Act 2004 and the Corrections Regulations 2005. Inspectors of Corrections have extensive powers under section 29 of the Corrections Act 2004. The Inspectorate, while part of the New Zealand Department of Corrections Ara Poutama Aotearoa, is operationally independent to ensure objectivity and integrity.

The value of prison inspections in closed environments

The Inspectorate conducts a programme of prison inspections (around four every year) which provide a ‘window into prisons,’ giving early warning of emerging risks and challenges, and highlighting areas of innovation and good practice that other prisons are encouraged to follow. The inspections are guided by Inspection Standards to deliver independent and objective assessments of the treatment of and conditions for prisoners in New Zealand.

Standard 44 requires that ‘Prisoners at risk of self-harm or suicide are supported in a therapeutic environment with trained staff who are resourced to meet their individual needs.’¹ This describes the standards of treatment and conditions we expect a prison to achieve. Inspectors consider the following Indicators when assessing the prison’s performance:

* All staff are trained in identifying self-harm and suicidal behaviour, and suicide prevention.
* Prisoners at risk of self-harm are placed in an environment where they can easily access the clinical support they need and a purposeful regime with meaningful activities and regular engagement with other people.
* All staff engage in a supportive and constructive way with prisoners in mental crisis, in a culturally appropriate way.
* Prisoners being managed in an alternative or restrictive regime due to their risk of self-harm are consulted and informed about their care, including how to return to a standard regime.
* Any prisoner being managed in an alternative or restrictive regime due to their risk of self-harm should be visited daily and as frequently as is necessary by a health professional to monitor physical and mental health.
* Responses to risks of self-harm and suicide are gender-specific and culturally appropriate.

Inspection reports, including findings, are publicly released and placed on the Inspectorate’s website. Prison general managers are expected to provide action plans to address the findings of each report and the Inspectorate monitors each site's progress.

The death in custody investigation process

Each year around 24 people die in New Zealand prisons and, pursuant to a memorandum of understanding between the Chief Executive of the Department of Corrections and the Chief Ombudsman, the Inspectorate conducts a comprehensive investigation into every one of these deaths. Around 60 percent of deaths are from natural causes (i.e. have a medical cause), and 40 percent are categorised as ‘unnatural’ (which includes suspected suicide, homicide, accidental or other non-natural deaths). In the past three years, there have been four homicides in New Zealand prisons ‒ three where the alleged perpetrator shared a cell with the deceased person. These homicides are investigated separately by New Zealand Police.

Inspectorate investigations examine the circumstances of each death, including the natural deaths, to understand what happened and identify any matters arising from the prisoner's management in prison. Investigations are conducted by Inspectors from the Inspectorate (Regional Inspectors who have custodial expertise, and Clinical Inspectors who are registered nurses), because health and custodial issues often intersect. Broad terms of reference and statutory powers enable Inspectors to widely investigate all aspects of a deceased person’s management while in Department of Corrections’ custody. The Chief Inspector writes to the family of each person who has died to explain the Inspectorate’s role in investigating the death and reporting to the Coroner. Inspectors are available to family members to discuss the investigation process.

Once the report has been drafted, there is an extensive quality assurance process. This includes comprehensive scrutiny by the Chief Inspector and legal review by the Inspectorate’s Principal Legal Adviser.

The draft investigation report, with findings and recommendations, is provided to the Department of Corrections under a natural justice process, generally with four weeks permitted for a response. This allows the Department to check for factual accuracy and respond to the recommendations. The Department provides a formal letter in response. This letter is appended to the report, which is finalised and provided to the Chief Executive, the Coroner, and the Ombudsman.

Our reports are not released publicly, as in some jurisdictions, out of respect for the privacy of the individual deceased prisoner and also because of Coroner’s Act restrictions on publications of certain matters. The family of the deceased person can request a copy of the report from the Coroner. Under the Coroners Act 2006, every “death in official custody or care” is reported to the Coroner. Coroners hold an inquiry (either “on the papers” or in a formal hearing (inquest) in a Coroner’s court) about how a person died. Coroners issue findings and can make recommendations or comments that might prevent a similar death in the future. The Coroner rules on the cause of death, and only the Coroner can rule a death as a suicide.

Deaths from assumed natural causes

With the growing and ageing prison population, the Department of Corrections can expect to respond to an increasing number of prisoners who die from terminal illnesses and the diseases of old age. In these cases, death in custody investigations focus on whether the access to, adequacy of, and provision of health care met the required standards.

Prevention and education focused thematic investigations for assumed unnatural deaths

As well as investigating individual deaths, the Inspectorate has undertaken thematic investigations into suicide and self-harm, and separation and isolation, to gain wider insights into the prison environment and management of prisoners. These are prevention and education focused reviews, aimed at providing insights and recommendations to the Department of Corrections which can help drive change and improvements.

In June 2023, the Inspectorate released a thematic report, Separation and Isolation: Prisoners who have been kept apart from the prison population.² The report noted: “The effects of segregation, solitary confinement, isolation, separation, and any other form of restrictive imprisonment, however this is described, demands the closest of scrutiny by oversight agencies” (p.3). Quoting the World Health  Organisation’s report, Preventing Suicide in Jails and Prisons,³ the Inspectorate noted: “The majority of suicides in correctional settings occur when an inmate is isolated from staff and fellow inmates. Therefore, placement in segregation or isolation cells for necessary reasons can nevertheless increase the risk of suicide" (p.16).

The report recommended that “Corrections must recognise the profound isolation experienced by segregated and at-risk prisoners, including that many are likely to be subject to solitary confinement as that term is defined by the Mandela Rules,” and “do more to mitigate the extent of the isolation experienced by such prisoners, especially where that isolation is beyond 15 days.” These recommendations (and five others) were accepted by the Department, leading to its first acknowledgement that solitary confinement and, in some cases, prolonged solitary confinement, was occurring in New Zealand. The Department said the report “outlined for Corrections a compelling case for change” and agreed to “work across Corrections to develop a long-term, system-wide plan for
enduring change” (p. 102).

Our companion report, Suspected Suicide and Self-Harm Threat to Life Incidents in New Zealand Prisons,⁵ published in February 2024, had significant areas of commonality; those separated or isolated whilst in prison are often involved in serious self-harm incidents or, sadly, die by suspected suicide. The genesis for this work was our concern that the number of suspected suicides and serious self-harm
threat to life incidents in New Zealand was increasing. Given that individual reports of deaths in custody are not published, we thought it imperative to examine and report on this systemic concern publicly. The Suspected Suicide and Self-Harm report acknowledged: “There are no easy solutions when it comes to suicide and self-harm prevention in prisons. However, there are practices and interventions that can help to save lives and reduce self-harm incidents. Corrections has a duty of care to all people in prison and must do everything it can to identify and mitigate the risk of suicide and self-harm" (p.17) The report noted that 62% of prisoners who died by suspected suicide during the five-year review period (1 July 2016 to 30 June 2021, when 29 people died of suspected suicide) did so within their first 100 days in prison; 38% were in prison for the first time.

The report found “remand prisoners experience many known risk factors for suicide and self-harm, including social isolation, restrictive regimes, uncertainty over court outcomes, alcohol and other drug withdrawal and lack of purposeful activity” (p.9).

Quoting the Comorbid Substance Use Disorders and Mental Health Disorders Among New Zealand Prisoners,⁶ the Inspectorate’s thematic report7 noted: “Prisoners have a higher incidence of known risk factors for suicide and self-harm than people in the general population. For example, nearly all (91%) people in New Zealand prisons have a lifetime diagnosis of a mental health or substance use disorder, compared to 40% of people in the general population. Prisoners with a mental health disorder (such as an anxiety or mood disorder) have the highest rates of recent or lifetime suicidal behaviour; almost two thirds (62%) of people in New Zealand prisons meet the diagnosis for either a mental health disorder or a substance use disorder” (p.18).

As of July 2025, prisoners aged 65 years and older made up 4% of the New Zealand prison population, of whom 98% were men and 2% were women. Those 55 years and older made up 11.8% of the population. While older people in prison are often defined as those aged 65 years and over, it is important to recognise that many people in prison experience earlier onset of ageing, with complex health and
disability needs emerging well before this age. This is particularly relevant for Māori, who face significant inequities in health outcomes.

While prisoners can apply to the New Zealand Parole Board for compassionate release if they are seriously ill and unlikely to recover, the reality is that many elderly prisoners lack family support outside prison and struggle to find suitable accommodation to enable release.

Prisoners with a terminal illness should have an end-of-life care plan, just as they would from their primary health carer if they lived in the community. The plan is intended to ensure that people who are dying can expess what is important to them about their care and can live comfortably as possible until they die.

These issues were discussed in our August 2020 thematic report, Older Prisoners: The Live Experience of older people in New Zealand prisons.⁸

The role and value of oversight in the investigation of deaths in prisons

As an oversight entity, the Inspectorate is one of the few jurisdictions which conduct death in custody investigations, prison inspections and thematic investigations (such as those outlined in this article) alongside our other statutory functions including responding to complaints.

The insights from this broad range of work undertaken by the Inspectorate provide us with a rich source of information to guide our decision- making about findings and recommendations that will make a meaningful difference to Corrections’ practices, policies, and procedures. Our determination, as an Inspectorate, is to deliver a reactive, preventive, and educative approach to oversight.

Without a ‘frank and fearless’ independent oversight mechanism, many of these insights may be missed, along with opportunities to improve the environment, conditions, and management of whose who are imprisoned in New Zealand.

And finally, but importantly, to acknowledge New Zealand’s indigenous Māori population, who are over-represented in the prison system, the Inspectorate was gifted a karakia (traditional Māori incantation or prayer), which is included in the final report for each Māori prisoner who dies in custody.

Tūmatauenga is the deity of war and people, Whiro is a personified form of sickness, disease and death, and Rongo is the god of peace (Te Ara Encyclopaedia of New Zealand).

Endnotes

¹ Inspection Standards: Criteria for the treatment of and conditions for prisoners: Office of the Inspectorate. June
2026.
² Separation and Isolation thematic report: Prisoners who have been kept apart from the prison population. Office
of the Inspectorate. March 2023.
³ Department of Mental Health and Substance Abuse, Preventing Suicide in Jails and Prisons. World Health
Organisation. (2007)
⁴ See endnote (2)
⁵ Suspected Suicide and Self-harm Threat to Life Incidents in New Zealand Prisons 2016-2021 thematic report.
Office of the Inspectorate. September 2023.
⁶ Indig, D., Gear, C., & Wilhelm, K. Comorbid Substance Use Disorders and Mental Health Disorders Among New
Zealand Prisoners. Wellington: Department of Corrections. (2016)
⁷ Thematic report: Older Prisoners – The lived experience of older people in New Zealand prisons. Office of the Inspectorate. August 2020.
⁸ Older Prisoners: The Lived Experience of older people in New Zealand Prisons