Source: Radio New Zealand
Master Control staff claim the calls were overlooked, because they were very busy. RNZ/Calvin Samuel
A coroner is critical of Department of Corrections staff for failing to answer calls for help the day an inmate was found dead in his cell.
After an inquiry into his death, coroner Katherine Greig has determined Anh Tuan Nguyen died by suicide at Auckland’s Mount Eden Corrections Facility (MECF) in 2017.
Greig said, on 14 September, the morning he was found dead, his cellmate repeatedly rang the cell intercom, but corrections staff took almost 90 minutes to answer.
The coroner’s reports said the cellmate’s first call at 6.18am was activated at MECF’s Master Control, which controlled the prison alarm cell system at that time.
The cellmate reported to have kept pressing the bell what “must have been a hundred times”, waiting for an answer.
“I am not critical of his actions.” Greig said. “I am critical of the failure of staff, whose responsibility it is to monitor the safety of prisoners and ensure appropriate responses to prisoners identified as being in danger, to answer the prisoner’s call bell in a timely way.”
After Nguyen’s death, an investigation was carried out by Corrections inspectors.
The investigators found that, at 7.43am, control of the alarm system was transferred from Master Control to Alpha Unit at the request of a day shift officer, who had just started his 8am-5pm shift.
The officer answered Nguyen’s cellmate’s call at 7.47am and immediately requested assistance.
At 7.51am, the two corrections officers and a nurse who were doing the morning medication round arrived outside Nguyen’s cell.
The nurse concluded that Nguyen had been dead for some time, as rigor mortis had set in, and the nurse instructed staff not to begin cardiopulmonary resuscitation.
Nguyen was pronounced dead at the scene.
Investigators reported that, out of eight prisoners who made calls to Master Control between 6-8am on 14 September, only one was answered.
“On the morning Mr Nguyen was found dead, Master Control staff involved failed to prioritise answering calls from prisoners appropriately, and treated such calls in a casual and cavalier fashion,” Greig said.
“The inspectors’ report records that, from about 6am, Master Control is busy, as staff have responsibility for early unlock of prisoners for court and prisoners working in the kitchen. The officer in charge of Master Control on 14 September stated that the calls on 14 September were not answered between 6-8am because the site was very busy at the time and the calls were overlooked.”
The inspectors concluded that Master Control staff did not follow the processes to treat calls as a priority, and that the failure to answer the cell alarm call for one hour and 30 minutes was unacceptable.
Coroner Greig said it was troubling that this was not the first death of a prisoner she had dealt with where a failure to answer a prisoner call to Master Control had been an issue in the death.
In 2008, Anna Kingi’s heart failed while she was being held at the Auckland regional women’s prison. Guards took 13 minutes to find the keys to unlock her cell and give her medical attention, by which time it was too late to save her.
“It is deeply concerning that, almost 10 years after Ms Kingi’s death, similar issues relating to failure to answer prisoner cell calls by Master Control again arose in a New Zealand prison.
“It is also disturbing that the level of non-compliance by Corrections staff on the morning of Mr Nguyen’s death was so poor that the inspectors of Corrections who carried out the inquiry needed to recommend to the Prison Director of MECF that Master Control staff be reminded of their basic obligations.”
The coroner recommended that Corrections reviewed its practices nationwide to ensure prisoner call bells were answered in a timely manner.
She advised that Corrections remove the ability to manually or digitally subvert, snooze or otherwise ignore calls, support prisons to determine which calls were urgent and how calls determined to be non-urgent were managed, as well as ensuring the final response outcome was recorded.
She also advised Corrections to look at whether Master Control staff across all prisons had complied with expected standards since Nguyen’s death and ensuring staff were able to respond to calls during “routinely busy” times.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
