Summary of a case review of the management of a prisoner at Auckland Prison


On 27 April 2016 the Chief Ombudsman via the COTA team raised some areas of concern with the Deputy Chief Executive, Corporate Services in relation to a prisoner’s treatment and that their overall view was that; ‘The use of the tie-down bed in the particular case of the prisoner was inhumane, dehumanising and could amount to torture under the Crimes of Torture Act.’

As a result the Chief Executive determined that the management of the prisoner should be fully investigated by the Chief Inspector of Corrections.  The Investigation into the management of the prisoner during the period 27 February 2016 to 3 May 2016 was carried out by Louise MacDonald, Inspector of Corrections on behalf of Andrew Fitzharris, Chief Inspector, under terms of reference approved by the Chief Executive.

The tie-down bed (TDB) restraints (consisting of a tie-down bed, wrist bed restraints and torso restraints) are a legal authorised form of mechanical restraints in accordance with Sections 87 and 88, Corrections Act 2004, regulations 124-129, and Schedule 5 Corrections Regulations 2005.

The Investigation methodology involved a review of all records relating to the prisoner’s management during the period 28 January 2016 to 3 May 2016; the prisoner’s electronic file, At Risk management file and management plans; prisoner’s electronic Health (including medical notes) file (Medtech) and Treatment Plan; the prisoner’s Department of Corrections psychological involvement and case file, and the prisoner’s Department of Corrections case management involvement and Offender Plan. The Investigation reviewed all relevant legislation, Departmental policy and procedures, including Memorandum of Understandings and Service Level Agreements. Further, the Investigation completed an interview with the prisoner, relevant Departmental staff and external agency personnel involved in the professional decisions relating to the prisoner’s management (Mason Clinic Psychiatrist and Mason Clinic Manager).

In February 2016 a prisoner was mechanically restrained via the TDB from 1600 hours to 0830 hours in response to an escalated risk of self-harm and infection following three incidents of self-harm (deep cut to abdomen and wound tampering) during February 2016.  There were also subsequent incidents of self-harm in March 2016.

The TDB continued to be used during 1600 hours to 0830 hours daily as part of the prisoner’s management plan which was aimed at reinforcing positive behaviours by reducing time restrained on the TDB.

The use of the TDB was discontinued in April 2016 by staff following joint agreement by the multi-disciplinary team; being Mason Clinic staff, psychological services, regional office staff, and Auckland Prison health and custodial management staff.

The prisoner concerned is reported to have severe borderline personality disorder and substance abuse (drug seeking) issues.  His personal records document a person who intentionally selects the timing of his self-harm to coincide with low staffing levels on site (custodial and health) to facilitate external medical treatment in the hope of facilitating specific drugs (pain-relief opiates).

The prisoner had regular involvement with Mental Health Services throughout his terms of imprisonment. Since being transferred to Auckland Prison in July 2015 he was admitted to the Mason Clinic following a series of self-harm incidents which resulted in the use of the tie-down bed consecutively for approximately 41 hours until being transferred to Mason Clinic, and then returning to Auckland Prison in September 2015.

The prisoner was transferred to the Mason Clinic (June 2016) following further self-harm attempts.  The prisoner was reportedly kept in isolation with the use of mechanical restraints under supervision of three staff whilst at Mason Clinic.

There are still serious concerns within Corrections Services as to the prisoner’s ongoing management and the risk of him seriously self–harming to the point that he will take his own life.  This is a heavy burden for the individual staff involved and the Department as a whole.

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