This week the Dunedin coroner, David Crerar, has been holding an inquest into the death of Jai Davis at Otago prison in February 2011 from a suspected drug overdose. It’s taken over three years for the the inquest to start – mainly because for 12 months after Davis died, the police did virtually nothing about it. It looked like a suicide, so they just weren’t interested.
When I heard what had actually happened, I made a complaint to the IPCA about the inadequate police investigation. As a result, Detective Senior Sergeant Colin Blackie was eventually appointed to conduct a more thorough investigation. He did an excellent job. Over 60 Corrections staff were interviewed – including the managers, officers and nurses who were at Otago prison at the time. That took another year.
How Davis died
The circumstances contributing to Davis’ death are complex. But in a nutshell, he was admitted to the prison on Friday, 11 February 2011 when the health centre manager, Jill Thompson, was mysteriously absent from her post. There was no doctor on duty either; there hardly ever is – see Prison deaths linked to Corrections refusal to employ sufficient doctors.
Because Corrections had been monitoring prisoner’s phone calls, both the Police and the Corrections Department were aware Davis was likely to be internally concealing drugs when they brought him in. Davis was put into an ‘At Risk’ cell which has a camera on 24/7. Staff were also supposed to physically check on him every 15 minutes. The checks weren’t carried out properly and over the next two days, Davis became visibly unwell. Although he was seen by half a dozen different nurses during the weekend, not one of them bothered to call the doctor. Davis died at about 10.00pm on Sunday, 13 February, after the nurses had all gone home.
Once Colin Blackie finished his investigation, senior police at head office analysed the information to determine whether anyone should be charged with a criminal offence – such as “failing to provide the necessaries of life”. That took another six months, but at the end of the day, no one was charged with anything. This week, the coroner was finally able to start the inquest into what went wrong.
Colin Blackie (left) partly blamed the slow start to the investigation. His testimony at the inquest was discussed on RNZ’s Checkpoint programme: ‘Delays into Jai Davis’ death impeded investigation’ (3’ 37”). A brief except follows:
Interviewer: “Emotions were running high as Detective Senior Sergeant Colin Blackie of the CIB told coroner David Crearer a tale of woes at the prison.”
Colin Blackie: “My view after what I believe was a thorough investigation is that over those few days (in February 2011 when Davis died), there was dysfunctionality within the prison. (I believe) that the three pillars of structure, communication and leadership were failing. There was a disconnect between the work groups (prison officers and nurses) and individuals (responsible for looking after Davis).”
“I use the analogy of five people trying to tackle Jonah Lomu. Everyone falls off and blames the others – and Jonah scores the try. And that’s how I viewed it at the end of this investigation. There was systemic failure by certain people and certain workgroups and no one standing up to be accountable for the treatment and care of Mr Davis.”
Jonah was a juggernaut
The analogy with Jonah Lomu is valid. Jonah was a juggernaut – defined as ‘any large, overpowering, destructive force or object’. Once he got going, he was virtually unstoppable. For rugby fans, it was always a joy to see half a dozen guys trying to tackle him at once. He would usually just crash into them, step over the top, and go on to score a try.
The Corrections Department is equally overpowering and destructive – to the extent that in the last 10 years, approximately 90 inmates have died ‘unnatural deaths’ in prison. Most of these deaths are described as suicides. But because prison conditions are so harsh, the suicide rate inside is on average seven times higher than in the suicide rate in the community. In 2011 when 11 prisoners committed suicide – not counting Jai Davis who died after internally concealing drugs – it was 11 times higher.
Despite the fact that most unnatural deaths in prison are ‘suicides’ – neglect or failure to provide medical treatment often contributes to those suicides. See the Southland Times story on the death of Richard Barriball, Prison staff ‘ignored concerns’; or the story about Kerry Joll who had a history of depression but received no treatment in prison and hung himself.
Corrections doesn’t ‘try’ at all
But here’s the real killer. Despite 90 unnatural deaths in our prisons in the last ten years, not one Corrections’ employee has ever been charged with a crime. Why? Because the Department is a juggernaut. It seems the police haven’t got the guts to tackle a government department that’s bigger than they are – or there’s political interference – and so Corrections gets away with it. But there’s a double standard; police frequently prosecute people in the community who neglect vulnerable family members. See severe neglect leads to prison sentence – except when the victim is a prisoner.
The inquest into the Jai Davis case shows the Corrections Department continues to get away with it – just like Jonah Lomu pushing all opposition aside. The only difference is that Jonah would go on to score a try. When it comes to saving prisoners’ lives, all too often Corrections doesn’t try at all.
When the inquest is finished, the coroner can make all the recommendations he wants. But until the police find the courage to prosecute prison officers and nurses who fail to respond to their duty of care, the Corrections juggernaut will continue steamrolling prisoners into committing suicide.