Key Findings

The Investigation is of the opinion that the decision to place the prisoner on the TDB in February 2016 was justified given his recent escalated self-harm behaviours and that the prison regimes and resources were not the cause of the prisoner’s placement on the TDB (from 1600 hours to 0830 hours) but rather a consideration given his historical self-harm occurred during these hours so as to facilitate hospital treatment in order to meet his drug seeking behaviours.

It is acknowledged, with hindsight, that there was a subsequent change in focus regarding the management of the prisoner and that he should have been removed from the TDB sooner.

The Investigation is of the view that due to:

  • A lack of legislative detail and comprehensive guidelines for use of the TDB restraints; and
  • The involvement of numerous staff from various disciplines throughout the prisoner’s time on the TDB; and
  • A lack of training of all Departmental staff (custodial, health, psychological services) in the purpose and restrictions in the use of the TDB restraints; and
  • A lack of sharing professional information (albeit acknowledging professional privacy restraints) and assumptions of how the prisoner was being managed on the TDB; and
  • A lack of a lead role overseeing the prisoner’s overall management

The use of the TDB crept from being used as a last-option resource to assist in reducing his immediate risk of self-harm, to a tool for managing his health, and complex behaviours.  The complexity of each risk however being inter-related and as such blurring the overall purpose of the TDB use.

Although there were procedural shortfalls and non-compliance with regulations and policies, overall the intentions were to maintain the prisoner’s wellbeing. The Chief Inspector noted that, to the extent to which I am qualified to judge, I do not believe the Department’s actions amount to torture.

Specific Findings

It is acknowledged that the decision to keep the prisoner on the TDB was a joint decision by those involved in the Multi-disciplinary Team (which included the Mason Clinic Prison Forensic team).

The Prison Director, who ultimately has responsibility for the prisoner’s safety and well-being, and is the decision maker on whether the prisoner would be placed on/off the TDB, is unlikely to go against professional advice received. (GP/psychiatrist & psychologist).

The Investigation found that the relevant legislation, delegations, national policy, procedures and instructions, and local site policy for the use of mechanical restraints (specifically the TDB) lacks alignment and robust guidance, and has contradicting requirements.

That the lack of review regarding the national TDB policy and procedures following the amendments to the Corrections Act 2004 & Corrections Act 2005 in June 2013 contributed to the confusion as to the correct application of the mechanical restraints process and the legal roles authorising use of the TDB mechanical restraints.

General Findings

The lack of timely reporting to the Regional Office caused a delay in identifying the authorisation breaches.

Though there were multiple people involved with the prisoner’s management during the initial period there was no one role overseeing and collating the whole process to ensure compliance.

That the Auckland Prison staff (custodial & health) working in an extremely volatile and stressful situation managed a complex, difficult prisoner to the best of their abilities and that the gaps in their knowledge and the policies and processes has opened staff up for criticism.

The Investigation found there was confusion specifically in relation to the medical and health practitioners’ responsibilities in accordance with the legislation and delegations, and how that translated to the national policies and procedures regarding the application of the TDB mechanical restraints.

The Investigation concurs with the findings regarding this matter as identified in the At Risk prisoners Review completed by the Northern Region in May 2016 which states that;

  • ‘There does not currently appear to be any current departmental clinical practice guidelines to enable the Medical Officer to reach a considered decision regarding the use of mechanical restraint.
  • There is also lack of clarity around what decision the Medical Officer is being asked to make in relation to the use of mechanical restraint and whether processes to make such decisions are reflective of safe clinical practice that supports a medical practitioner’s professional accountability.
  • In addition, there does not appear to be any current support or mechanism for the Medical Officer to peer review these decisions.’

The Investigation found that there were varying degrees of compliance with the relevant national policies and procedures as per the Prison Operations Manual (POM), Custodial Practice Manual (CPM) and local policy for use of the TDB.

The Investigation found there were no specific current national guidelines for use of the TDB.  However Auckland Prison had a local outdated policy containing instructions and guidance on using the TDB.  The Investigation found that the site did not comply with this local policy in that:

  • Restraints were applied to the ankles without specified medical advice
  • Limbs were not exercised
  • Recording of fluids & foods was not completed to an acceptable standard.

The Investigation found that the local policy requirement regarding placing a urinal bottle between a prisoner’s legs during general lockup in the Investigations’ view is degrading and should immediately be removed from the local policy.

The Investigation found that the circumstances in which the prisoner was placed on directed segregation for Medical Oversight pursuant to section 60(1)(a) in January 2016 and Section 60(1)(b) in February 2016 were appropriate and reasonable; authorised by the delegated authority on the Health Centre Manager’s recommendation with the required authorisation form completed.

The Investigation is of the view that the use of the TDB for the prisoner was a last resort for prison management who believed he would be admitted to the Mason Clinic as had occurred in similar circumstances five months earlier.  However when he was assessed as “not mentally ill” by the Mason Clinic psychiatrist, the pressure was placed back on custodial & health staff to manage his self-harm risk behaviours.

The Investigation is of the view a more strategic consideration of the staff placement in the At Risk Unit needs to be a focus moving forward which includes robust training and supervision.

The Investigation found that there is a Human Resource guide developed to assist managers involved in making staff placement decisions into units defined as high risk and to assist staff in understanding how these decisions are made and what they need to do to contribute in these environments.

The Investigation acknowledges the contribution the COTA Inspectors’ have played in the process of identifying the shortfalls within the Department’s TDB policy and also the involvement of Northern Regional Office staff in dealing with these shortfalls when identified.

The Investigation is of the view that a single management role was required to ensure all levels of involvement in the prisoner’s management was collated and processes complied with appropriately.

The Investigation is of the view that the Prison Director who is legally responsible for any prisoner while imprisoned at his/her site should have access to all relevant information/documentation pertaining to that prisoner which includes general Health, psychological & psychiatric information to enable an informed decision.

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