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Department of Corrections protocol with Ombudsman regarding death in custody

Prisoners / Corrections
Ombudsmen Act 1975
Related legislation:
Fire Services Act 1975
Legislation display text:
Ombudsmen Act 1975, Fire Services Act 1975
Hon Anand Satyanand
Case number(s):
Issue date:

Death in custody—application of Protocol between Department of Corrections and Office of the Ombudsmen—issues arising from monitoring departmental investigation—need for improved communication, videotaping, fire safety and emergency procedures

In February 1998, an inmate at Auckland Prison died as a result of setting fire to his cell.

In terms of the Protocol between the Department of Corrections and the Office of the Ombudsmen, the Department takes principal responsibility for the investigation of an inmate’s death in custody. The role of the Office of the Ombudsmen is to monitor that investigation. However, it is open to an Ombudsman to initiate an own motion investigation into the circumstances of the death if issues arise which the Ombudsman considers warrant such a course.

The monitoring role is assumed by an Investigating Officer with special responsibility for penal institutions. That officer keeps the relevant Ombudsman informed about the progress of the Department’s investigation and any issues of concern as they emerge. The officer provides the Ombudsman with a written record of the outcome of the monitoring role and the Ombudsman generally makes that information available to the Department.

In the course of monitoring the Department’s investigation of the death of the inmate at Auckland Prison in February 1998, a number of procedural issues came to light. It became apparent that the inmate concerned had made threats to staff during the day that he would set fire to his cell. Discussions had been held with the inmate who had appeared to calm down. Relevant entries had been made in the inter-unit communications book for the unit where the inmate was housed, but there appeared to be no standard procedure for notifying staff coming on duty of potential problems arising from earlier shifts. Apparently, it was not common practice for patrol staff to read the inter-unit communications book. Accordingly, the patrol staff had not been alerted to the potential problem with the inmate concerned so no changes had been made to the normal intermittent after-hours patrol of the unit. In the circumstances, it was concluded that procedures needed to be set in place to ensure that relevant information is made available to staff as they come on duty.

Another issue related to the retention of videotapes to assist in the investigation of incidents. In this case, it appeared that a videotape made of the incident had been used the following day to monitor visitors and was not therefore available to the investigators.

The Department’s investigation also highlighted the need to upgrade fire detection and prevention measures at the prison. In addition, it was established that Auckland Prison was not complying with s 21A of the Fire Services Act 1975 which requires the provision of an approved evacuation plan or the grant of a waiver from those requirements.

Following consideration of the report prepared by its investigators and consideration of the issues which had come to light in the course of the monitoring of the investigation, the Department advised that a new procedure had been instituted for inter-shift briefings. In addition, revised procedures for the inter-unit communications book had been implemented and a notice board placed in the guardroom. These new procedures would all be used to pass information from one staff shift to another.

The Department also advised that the question of the retention of videotapes of incidents was a national issue to be addressed at that level. In this case, there had in fact been no videotape of the incident, but, pending development of a national policy, Auckland Prison had instituted its own procedure whereby tapes of incidents would be held for an indefinite period.

With respect to the need to upgrade fire prevention and detection measures, the Department advised that smoke detectors had been installed at regular intervals throughout the unit where the inmate concerned had been accommodated. The Department also advised it had entered into discussions with the Fire Service with respect to the requirements of s 21A of the Fire Service Act 1975.

This case note is published under the authority of the Ombudsmen Rules 1989. It sets out an Ombudsman’s view on the facts of a particular case. It should not be taken as establishing any legal precedent that would bind an Ombudsman in future.

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