Deaths in custody

The death of a family member, whānau or friend is hard at any time.

The Department of Corrections – Ara Poutama Aotearoa ensures that all processes related to a person’s death in custody are carried out professionally, with integrity and respect to all involved. Every death in custody is investigated by the Office of the Inspectorate and the Coroner. Some deaths may also be investigated by other agencies such as the Office of the Ombudsman or the New Zealand Police. These investigations make sure lessons are learned, and improvements made.

Any concerns you have will be taken seriously, and Corrections staff will be available to speak to you.

What happens when a person dies in prison?

The process when a person dies in custody:

  1. Custodial and health staff manage the emergency response until emergency services arrive.
  2. Prison nurses or paramedics verify that death has occurred.
  3. Prison General Managers inform the Police, the Coroner, and the Department of Corrections’ National Office.
  4. Police notify the next of kin.
  5. The duty Coroner’s Office organises the removal of the body from the prison for a post-mortem to be carried out if necessary.
  6. When the body is removed, prison staff secure the area where the person died.
  7. Police can refer families, whānau or friends to support services as required.
  8. Prison staff organise for a deceased person’s property to be passed to a nominated contact.
  9. The cell where the person died is blessed by a Chaplain or Kaumatua.
  10. The Office of the Inspectorate investigates the death in custody.
  11. The Coroner conducts an inquiry and issues a final written finding.

The post-mortem examination

The Coroner decides if a post-mortem examination should be carried out to find out why the person has died. A post-mortem examination is an autopsy, a medical examination of the body of the person who has died.

The duty Coroner’s office will organise a funeral director to collect the body of the person who has died. The Coroner will consider the wishes of the family and whānau when deciding if a post-mortem examination is needed.

What you can decide:

  • If you do not want a post-mortem examination, you must tell the duty Coroner’s office as soon as possible.
  • Tell the duty Coroner’s office if you want to view or stay with or near the body while it is with the Coroner. The Coroner will consider cultural and spiritual aspects when they make their decision.

The deceased person’s body

After the post-mortem examination, the body of the person who has died is released to the family or whānau.

The Department of Corrections will pay for the cost of transporting the body to the place of burial in Aotearoa, New Zealand. Your prison contact person will be able to tell you more about this. Work and Income and ACC may be able to help with additional costs.

The deceased person’s property

The deceased person’s property can be collected from the prison, or the property can be couriered to a nominated address, at Corrections’ cost. Any money in their trust account will be passed to their nominated contact person.

The place where they died

Sometimes, a memorial service will be held in the prison, and the place where the person died will be blessed. It may be possible for relatives to view the place in prison where their loved one died.

If you feel this would help you in the grieving process, please contact the prison's General Manager.

A prison liaison person, such as a Chaplain will be able to help with any further questions you may have.

The Office of the Inspectorate investigation

The operationally-independent Office of the Inspectorate – Te Tari Tirohia is required to investigate every death in custody.

  • Inspectors look into the circumstances of the death to understand what happened and identify whether policies, procedures or practices need to change.
  • Investigations of deaths due to natural and/or medical reasons (such as cancer or heart attack) focus mainly on health care. Inspectors seek information from health experts and others, as required.
  • When the Office of the Inspectorate completes its investigation, it gives the report to the Department of Corrections’ Chief Executive and the Coroner.

Other agencies

The Office of the Ombudsman will also consider whether it needs to conduct a separate investigation. If there are criminal circumstances surrounding a death, the Police will conduct their own investigation.

Coroner’s inquiry

The Coroner is an independent judicial officer who looks into the facts of a death. Coroners open inquiries to find out more about the deceased person and where, when, and how they died. If a person dies in custody, an inquiry must take place. It is difficult to predict how long an inquiry will take because every death is different and the Coroner needs to collect evidence from many sources. Coronial Services (the Coroner’s office) will keep you up to date at each stage of the coronial process.

  • A hearing happens towards the end of an inquiry. This is when the Coroner looks at all the evidence that has been gathered and decides on the facts of the death. At a hearing the Coroner makes a finding in their office (chambers) after reading all the evidence.
  • If the Coroner needs to hear from witnesses in person, they will hold a hearing in court. This is called an inquest.
  • The Coroner always issues a final written finding – a report about the facts of the death.
  • The Coroner might also make recommendations or comments – directed towards individuals and organisations – in their findings to help reduce the chances of other deaths in similar circumstances. The findings are public documents.

When an inquiry is closed, you can ask for a copy of the findings by contacting Coronial Information:

Coroner’s inquest

If the Coroner decides an inquest is needed, Coronial Services will make sure the family or whānau of the person who died are kept up to date with what’s happening. The inquest is normally held at the local court. Coronial Services will tell you where and when it will take place. Attending the Coroner’s inquest can be an important part of the grieving process. This could be the first time all the details and circumstances of the death are presented.

You can discuss any concerns you have about the inquest with Coronial Services.

  • The Coroner oversees the inquest and is responsible for everything that happens in the courtroom.
  • Witnesses and experts speak or read statements.
  • Statements might include the pathologist’s post-mortem report.
  • The Coroner can ask the witnesses and experts questions.
  • The immediate family, whānau or their lawyer can also ask relevant questions.
  • The Coroner might say something about their finding at the end of the inquest.
  • Inquests are normally open to the public and media may attend.

You can find more information on the coronial process in the booklet: When someone dies suddenly. This booklet can be downloaded from

If you have concerns

If you have concerns with any part of this process, you can contact any of the following people at the prison: the Prison General Manager, Chaplain, or prison liaison person. You can also raise concerns with the Office of the Inspectorate, the Office of the Ombudsman, the Health and Disability Commissioner, or Coronial Services.

The Office of the Inspectorate
Mail: Private Bag 1206 Wellington 6140
Telephone: 0800 225 697

The Office of the Ombudsman
Mail: PO Box 10152 Wellington 6143
Telephone: 0800 802 602

The Health and Disability Commissioner
Mail: PO Box 1791, Auckland 1140
Telephone: 0800 11 22 33

Coronial Offices
Mail: DX Box: SX11166 Wellington