Prison is where society sends its mistakes

“Prison is where societPrisonery sends its mistakes. Everyone inside is there because society has failed them.”

This is the key  statement by Paul Little in a column in the New Zealand Herald today. Little was commenting on the recent reports of gang violence in Mt Eden prison; he goes on to describe the tragic backgrounds of so many of the people we send to prison in this country. For instance…

“The case of the 13-year-old boy who endured the most squalid of upbringings before stabbing dairy owner Arun Kumar is extreme but not unique.

“He is just one of hundreds of people who grow up knowing nothing but violence and cruelty where there should be love and nurturing. Plenty more such children live on our streets, forging lives of desperation, their ultimate incarceration only a matter of time.

“Another considerable proportion of the prison population is made up of people who are there because we no longer have hospitals to cater for the mentally ill. Those who can’t find a place in the community are locked up where they won’t be a bother – to us, at least.

“That number also includes those who committed crimes under the influence of drugs, including alcohol. Drug addiction is a mental illness that should be treated as such….”

Little comes to the conclusion that…

“A prison is not a pound for humans, where we abandon animals we can’t control any more. We are all responsible for them being there as long as we support the system that puts them there.”

It’s encouraging to see prisoners described in the media as human beings instead of losers or ‘psychos’ (Patrick Gower, TV3 News, 10 November.) Its even more encouraging to see responsibility for their failure placed where it lies – on society, on you and me.

Ombudsman colludes with Corrections to cover up responsibility for ‘unnatural’ prison deaths

The death of Jai Davis in 2011 has highlighted critical deficiencies in the management and nursing culture at the Otago prison. Now there’s an even wider concern. Documentation has come to light showing the Ombudsman colluded with Corrections, albeit unintentionally, to cover up the circumstances surrounding his death which implicate management and nurses at the prison.

This is how it happened. When a prisoner dies suddenly from an unexpected death, this leads to at least three different investigations – one by the Corrections Inspectorate, which is monitored by the Ombudsman; one by the Police, which may be monitored by the IPCA (if there’s a complaint); and finally one by the Coroner. Each investigation has a different focus.  The role of the Inspectorate is to determine whether any Corrections procedures or protocols were breached, and whether any prison officers should be disciplined. The Inspector also makes recommendations to the chief executive to prevent it happening again.

David MorrisonCorrections Inspector David Morrison’s report 

Responsibility for investigating Jai Davis’ death on behalf of the Corrections Inspectorate was given to David Morrison (right).  While interviewing prison staff about the circumstances, he was accompanied by a representative from the Ombudsman’s office. The Ombudsman’s role was twofold: to ensure Mr Morrison did his job properly, and to ascertain whether Mr Davis received appropriate medical care and had been treated humanely while in prison. In other words, the Ombudsman was supposed to ensure the Inspector got to the bottom of what Corrections did right – and what they did wrong.

Mr Morrison never got to the bottom of anything. (Here’s the executive summary of his report.) He was well aware that Acting prison manager, Ann Matenga, had statutory responsibility to advise the Medical Officer that a prisoner had been admitted suspected of having drugs on board – but never held her to account for not doing so. Mr Morrison also failed to make any findings against the nurses, even though they clearly failed to provide Mr Davis with adequate medical treatment.  The only staff he made findings against were two officers who made fictitious observations that Mr Davis was snoring in the early hours of Monday morning – by which time he was already dead.

David Morrison’s recommendations

Mr Morrison refused to point the finger at anyone further up the chain of command. His key recommendation was that:

“The Department of Corrections considers establishing a protocol with the Ministry of Health to facilitate the x-ray of a prisoner where it is suspected a prisoner is internally concealing an unauthorised item that in the opinion of the Medical Officer may place the prisoner’s health at risk.”

Corrections already had a protocol in place to manage that situation. It said that when a prisoner is suspected of internal concealment, the Medical Officer is to be advised. The problem is that since the nurses and prison managers ignored the existing protocol, they could just as easily ignore any new protocol. So that wouldn’t be much help. To address that difficulty, Mr Morrison’s second recommendation was:

“All key prison staff and health service personnel are trained and adhere to the requirements under the Prison Service Operating Manual (PSOM)…”

Great – except that Corrections staff are already trained in the PSOM – it’s like the prison officers’ Bible. All they have to do is look it up to see what to do in any given situation.

The nursing culture at Otago prison

The reality is that Mr Davis’ death had nothing to do with a lack of training.  It had to do with a lack of compassion and personal responsibility. The nurses who ‘treated’ Mr Davis, but refused to call the prison doctor, were all trained health professionals. They have two Bibles of their own – the Nurses Code of Ethics and the Code of Conduct. These describe the ethical and legal responsibilities that nurses have to their patients, irrespective of Corrections Department protocols. The problem was they ignored their ethics and the Code of Conduct because of a culture of incompetence and indifference that operated in the Otago prison health centre.

The only way to change that culture is for the nurses who are guilty of professional misconduct to face a Departmental employment investigation and be brought before the appropriate disciplinary bodies – which would include the Nursing Council and the Heath & Disability Commission. If the police did their job properly, and prosecuted nurses who were guilty of gross neglect, some of them would also be brought before the Court.

But Mr Morrison made no such recommendation.  His 44 page report does not hold anyone to account for their failure to call the prison doctor – despite the fact that this was the most significant act of negligence in a succession of negligent acts culminating in Mr Davis’ death.  In other words, Mr Morrison’s report was a whitewash.

Bev WakemThe Ombudsman’s response

Here’s the crunch. Despite the report’s obvious deficiencies, in September 2011 only six months after Davis died, the Chief Ombudsman, Dame Beverly Wakem (left) wrote to the Chief Executive of Corrections praising the Inspector’s conclusions. She said:

“My investigator monitored the investigation throughout. I have been provided with the Inspector’s final report and… I am of the opinion that the report is fully satisfactory and that the recommendations made by the Inspector are reasonable.”

In hindsight, that endorsement looks increasingly bizarre. At the time it was written, the police had barely begun their investigation.  Who knows what crimes they might uncover? Once the police finally finished (three years later), coroner David Crerar, was able to get on with his inquiry.  After hearing from 58 witnesses, the shortcomings in Mr Morrison’s investigation were disturbingly obvious and led to heated cross-examination at the inquest.

The inquest also highlighted the inadequacies of the police investigation (which led to three complaints to the IPCA), as well as the shoddy treatment provided to Mr Davis by the nurses and prison managers. The coroner was so concerned at the multitude of mistakes by those responsible, he said he intended to make adverse comments about everyone involved including: “Jai Davis, his associates, the police and certain police officers, Corrections management, certain Corrections staff and certain health centre staff.”  

Even the police began to realise they might have got it wrong. On the last day of the inquest, they announced they would review their decision not to lay charges against those involved.

The Ombudsman’s role

Given what we now know about this case, it is hard to understand why the Ombudsman would so quickly, and naively, jump to the conclusion that the report by Corrections Inspector David Morrison was ‘fully satisfactory’.  The Ombudsman’s role is to look after citizens’ interests in their dealings with government agencies – which includes ensuring that prisoners are not subject to cruel or inhuman treatment. But if Dame Beverley’s monitoring of Corrections is so superficial that all she does is send a representative to keep the Inspector company and then endorse his report, she’s not doing her job.  The Ombudsman is supposed to be the citizens’ watchdog. The message this case sends is that the watchdog is little more than a lapdog – one with no teeth.

The reality is that David Morrison’s recommendations completely missed the mark. That could be due to incompetence.  A more likely explanation is that Mr Morrison was trying to protect the reputation and careers of prison management and nurses by minimising the extent of their involvement in Davis’ death.  Why? Because Corrections Inspectors are not independent of those they investigate.  Mr Morrison is part of prison management; he’s hardly going to find fault with his own team.

How independent is the Ombudsman?

But the Ombudsman is independent, theoretically.  She doesn’t work for Corrections – or does she? I’m not so sure anymore. Dame Beverley has endorsed Mr Morrison’s flawed report that makes no findings against prison management. Maybe she doesn’t work for them, but she’s clearly supporting their team.  Here’s a bigger question. Is the lack of independent oversight by the Ombudsman in this case typical of oversight into the Best-Sleeping-Dog-Wallpaper-HD-0007other 90 unnatural deaths which have occurred in prison in the last ten years?

The answer is – nobody knows, because the prisoners are all dead. And they’re not really in a position to lay a complaint. Even if they were – that wouldn’t help much if the watchdog just sniffs around the Corrections Inspector’s feet, and then goes back to sleep.

Prisoner dies because Corrections reluctant to pay $300 for doctor on weekend

Jai Davis died from a drug overdose two days after being remanded to Otago prison in February 2011. The inquest into his death starts in Dunedin next week – on Monday 24 November, 2014. The hearing is likely to last two weeks and will expose numerous failings by prison management, prison nurses and prison officers who all knew Davis was ‘internally concealing’ drugs but never bothered to call a doctor or an ambulance.

InternalHere’s the background. Knowing he was going to be arrested, Davis tried to smuggle in codeine and benzodiazepines for some other prisoners. Corrections knew he had drugs inside him because they’d been monitoring phone calls from these prisoners asking Davis to bring in some ‘candy’ when he turned himself in.

The police also knew Davis had drugs on board because Corrections told them.  They asked police to keep him away from other prisoners when he appeared in court – in case he tried to pass the drugs on.

Once he was taken to prison, Corrections put Davis in a special ‘dry’ cell for ‘At Risk’ prisoners. These cells don’t have toilets. When the inmate wants to ‘go’, he is given a cardboard potty and is watched while he defecates. Once he’s done, prison officers look though the faeces to see what came out.  Corrections put Davis in one of these observation cells so they could catch him with the drugs and charge him with smuggling in contraband.

Prison manager failed to call doctor

The manager at Otago Correctional facility is Jack Harrison (below). OCFThroughout the two days that Davis was in prison, his team (managers, nurses and prison officers) broke all their own rules.  One of those rules is: “The Management of Prisoners Suspected of Internally Concealing Unauthorised Items”.  It clearly states that prison management is required to “inform a medical officer (a doctor) that the prisoner is being confined to a dry cell”.  The prison manager, Ann Matenga, who was on duty when Davis was admitted signed a form stating she would advise the doctor of the situation. She never did.

On the Sunday morning, two days after he was admitted, Davis was clearly not well. One of the prison officers who was monitoring him subsequently told police:

“The nurse was assessing Davis.  I stood at the cell door while she did this.  Jai (Davis) looked like a corpse, he was grey coloured and was scratching badly – his arms were real red.  His eyes were sunken and he had the cold sweats.  He was definitely not his usual self and he had slurred speech as well.  To my mind, he was showing all the signs of someone being on drugs.  What’s more his breath smelt like faeces.  I could smell it from where I was when he was talking to the nurse.  The nurse said he was fine and that was that.  I thought to myself, I am glad that’s your call, because to me, he looked as though he should have been in hospital.”

Another nurse who was on duty later that afternoon, Janice Horne, also thought Davis was under the influence of drugs. Corrections investigator, David Morrison, wrote: “Her assessment of Mr Davis at this time was that he was under the influence of some drug because of the slow movements that he was making”.   Janice Horne knocked off work at 8.00pm that evening and subsequently told Mr Morrison (and the police) that she saw no reason to call a doctor. She thought Mr Davis was fine, even though he was clearly under the influence of drugs. Davis died two hours later.  There was a camera in the cell recording every movement he made and the last one, the ‘death shake’, was at 10.01pm, two hours after Ms Horne went home. By the time prison officers realised he was dead – at about 5.00am the next morning –  his body was already stiff from rigor mortis.

Life is cheap in Otago prison

Davis was seen by five different nurses over the course of the weekend. They all knew he was in the ‘dry’ cell suspected of internally concealing drugs. Not one of them called the doctor. They didn’t even call the health centre manager. Nurses have a Code of Conduct which requires them, among many other obligations, to “Act promptly if a health consumer’s safety is compromised.” All five nurses responsible for Mr Davis’ health care over the weekend abandoned their ethics and ignored the Code of Conduct.

When the nurses were subsequently interviewed by the police and asked why they didn’t call the doctor, two of them said that cost was a factor. They said that calling the doctor out on the weekend was discouraged because the prison is 45 minutes’ drive from Dunedin where the prison doctor lived and a callout cost $300.  Life is cheap in Otago prison.

Despite so many Corrections staff failing to perform their duties in this case, not one Corrections manager, officer or nurse was charged with a crime. Why? Because the police also knew Davis was internally concealing drugs; with that knowledge, they held him in the police cells overnight and took him to court and then to Otago prison the next day. But they couldn’t be bothered calling a doctor either.  They just chucked Davis in prison. My guess is that the police didn’t want a judge, or the public, to find out that they also contributed to his death.

See also:

Police excuse for prisoner’s death – we didn’t read our emails! 

Severe neglect leads to prison sentence – except when the victim is a prisoner

Prison deaths linked to Corrections refusal to employ sufficient doctors

Corrections cuts crime with the selective use of statistics

In July 2014 the NZ Herald revealed the police have been cooking the crime stats in Papakura. Now The Daily Blog is asking the question: Has the Government manipulated Corrections statistics as well? The answer is yes.  But this is not being done by a few rogue Corrections officers. This is a systemic practice conducted in Corrections head office.

The Department claims it is focused on reducing reoffending and the diagram below taken from its website suggests that in April 2013, re-offending was down by 9.3% over the previous two years. The Department says it is on target to reduce reoffending by 25% by 2017.
When the government announced the goal of 25%, they said: “This will mean 600 fewer prisoners re-imprisoned one year after release, and 4,000 fewer offenders reconvicted within a year of beginning their community-based sentence.”

But the latest Corrections report (2013) on Trends in the Offender Population, effectively contradicts most of the Government’s claims about reduced reoffending.

Prison numbers

The report shows there has been no drop whatsoever in the number of people in prison (see graph).  In fact the number of sentenced prisoners has gone up dramatically – by 166% since 1983.Prison numbers

The best that Corrections could claim about this graph was that “From 2010 there has been a flattening in the sentenced prisoner population.”

Looking at it more closely reveals that the rate of increase also ‘flattened’ between 1983 and 1987; between 1992 and 1995; and between 1999 and 2003. After each of these ‘flatlines’, the muster continued its inexorable rise.

Offenders in the community

In regard to offenders on community-based sentences, the increase has been even more dramatic. The report says: “The number of offenders starting a new community sentence during 1983 was 14,407. This increased by 219 percent, to 48,379, in 2010.”  As with prison numbers, the overall trend is up, not down.Community numbers

But Corrections claims that: “The number of offenders starting a community sentence each year has decreased markedly since 2010. Between December 2011 and December 2013, re-offending has reduced, equating to 11.7% progress towards the target of reduced re-offending by 25 percent by 2017.” (See graph)

Sure, there has been a small drop in the last two years, but it is far too soon to determine whether this is anything other than a temporary dip in the upward trend. The report shows there was a similar drop between 1994 and 2000 – followed by a rapid rise to a new peak in 2010. Corrections’ exaggerated claims about the dip in the last two years are premature; they ignore the long-term upward trend in which the dip may be just a natural variation.

Selective statistics

In fact the dip is not natural. It’s entirely manufactured – by the selective use of flawed statistics.  To make it look like reoffending (by those on community based sentences) is down, Corrections only includes statistics of those who reoffend within 12 months from the start of their sentence, rather than within 12 months from the end of their sentence.  That’s ridiculous.  It’s like measuring the reoffending rate of prisoners while they are still in prison, with almost no capacity to commit further crime. No wonder the reoffending stats are down.

A more useful analogy is to compare reoffending rates with the survival rate of cancer victims. Measuring  survival from the start of chemotherapy or radiation treatment would not tell us much.  It’s only after treatment is complete, assuming the patient survives, that its effectiveness can be evaluated. This is done by measuring survival rates five or even ten years later. 

Short term snapshots

The same applies to criminal reoffending.  The reality that the longer a recidivist offender is at large in the community, the greater the chance he will eventually reoffend. A more detailed analysis conducted by Corrections (Reconviction patterns of released prisoners: A 60-months follow-up analysis) shows that approximately 26% of prisoners reoffend and are re-imprisoned within 12 months of release. But after five years – 52% are back in prison.  In other words, approximately half of all ex-prisoners who subsequently reoffend manage to survive in the community for more than 12 months before they commit another crime and go back to prison. But Corrections is not counting these crimes.

What this means is that the statistical data that Corrections is using to prove it’s on track towards the 25% goal comes from short term snapshots and is therefore incomplete and misleading.  For those on community based sentences the snapshot is so short, it begins at the start of the sentence while the offender may still be on home detention. This is a cynical and deceptive use of statistics which fails to provide an accurate or realistic picture of criminal behaviour in New Zealand.

Nurse suspended on full pay for 18 weeks for giving a prisoner Raro

Emily Wilson has been a nurse for 30 years. In 2009 she took a job at a prison – in the health unit at Otago Corrections Facility (OCF).    She described a litany of unethical and disrespectful behaviour by certain nurses at the OCF that went on in the two years she was there.

The green chit strategy

According to Nurse Wilson, some nurses at OCF went out of their way to make life difficult for prisoners.  One strategy involved green chits. When prisoners want to see a doctor, they have to fill in a green form – known as a chit. They describe their health problem on the chit and place it in a box. Each morning officers give the chits to the nurse on duty – bearing in mind, nurses are the gatekeepers to the doctor. If the nurse on duty didn’t like a particular prisoner, she would rip up his chit and throw it in the bin. He wouldn’t get to see the doctor – no matter how serious his health problem was.

Sometimes this nearly had fatal consequences.  Wilson described one prisoner at OCF who got really sick and had acute stomach pain.  He filled in the chits four days in a row. The nurses ignored him and told him to ‘toughen up’.   His condition deteriorated to the point that eventually the prison officers became concerned.  Because the nurses wouldn’t help, the officers carried the prisoner over to the health centre in a golf cart. That got the prison doctor’s attention; he called 111 immediately and the man had to be taken to hospital where he was found to have a burst appendix and septicaemia (blood poisoning). He survived – but only just – and only because untrained prison officers realised it was a life threatening situation. If it had been left up to the nurses, he would have died.

Denial of medication strategy

Another strategy used to inflict pain on prisoners is to deny them access to prescribed pain medication.  This strategy was used with fatal consequences on one prisoner who committed suicide in Otago prison in 2010.  While in the community, Richard Barriball needed three operations on his arm and, after the third, was still in severe pain.  He was prescribed four different pain killers by hospital specialists; two were opiates and another was a benzodiazepine – all three of which are addictive.  However, the Corrections Department discourages prison doctors from prescribing medications which are addictive.  So when Barriball was  remanded in prison on minor offending, he was taken off all three within a few days.

In pain and  withdrawal, he hung himself a few days later.  In his report into his death, the coroner wrote: “The causes of the death and the circumstances of the death of Richard Barriball have shown suboptimal care by OCF… (including) the failure of OCF to provide delivery of prescribed pain relief …”

Suspended over Raro

Nurse Wilson was appalled at the way Barriball was treated.  On one occasion when she showed compassion to another prisoner, they used the incident to suspend her.  Wilson had only been at the prison a few months when an alcoholic man was brought in. He was suffering from dehydration and withdrawal symptoms and was so disoriented, he was placed in the at risk unit to detox. The prisoner was so confused, he started drinking out of the toilet. Wilson spoke with the two officers on duty and the three of them decided to get him some clean drinking water.  One of the officers washed out a milk container and filled it with water and then Wilson poured half a sachet of Raro into it.

They went back to the prisoner, gave him some valium (used to assist alcoholics detox) with the Raro flavoured water and he ‘skulled it’. A few days later, Wilson was called into the health manager’s office and told to pack her things immediately. She was suspended for giving the prisoner Raro (which was not an approved item for prisoners) and was off work on full pay for the next 18 weeks.  The Department conducted an extensive investigation into this apparent breach of policy which ran to 238 pages. It concluded that Wilson had breached section 141 of the Corrections Act 2004 which says “every person commits an offence who…  delivers anything, or causes it to be delivered, to any prisoner inside a prison”.  Corrections management twisted this regulation to include Raro flavoured water given to assist a dehydrated prisoner to stop him drinking out of the toilet.

A couple of days after Wilson was suspended, the prisoner had to be taken to hospital – suffering from severe dehydration.  It seems Corrections aren’t keen on showing kindness to inmates.  They prefer to wait till it’s an emergency and then call an ambulance (at taxpayer’s expense), rather than break the Raro rules.