Coroner Bruce Hesketh will determine the cause of death of Waikeria Prison inmate Grant Whittal-Bell in 2019. Photo / Star News
WARNING: This article deals with self-harm and suicide and may be upsetting.
A new inmate with a history of self-harming who would later die by suspected suicide in prison, passed two risk assessments without any warning for those in charge of his care.
A Coroner's inquest into the 2019 death of Grant Whittal-Bell at Waikeria Prison has heard that the receiving prison guard did not know the first-time inmate had been in hospital several times for self-harm.
Department of Corrections officer Clint King was reliant on Whittal-Bell to provide details of his own mental health history during his induction into prison in October 2019.
Whittal-Bell was facing serious charges and was remanded in custody while awaiting court. The charges and the name and age of the complainant are suppressed.
The Rotorua man died while in isolation at the prison on November 17, 2019, exactly one month after he arrived. The way in which he died cannot be reported.
The "very distinctive" scars on Whittal-Bell's arms - later identified at autopsy as clear indicators of self-harm - were not noted during an arrival strip search that included photographs.
But King said the strip search was specifically focused on finding contraband.
King told coroner Bruce Hesketh he did not have any reports indicating Whittal-Bell was at risk although the prisoner told King during the assessment he tried to take his own life three years earlier.
King understood the attempt was linked to Whittal-Bell's medication for attention deficit hyperactivity disorder (ADHD).
Hesketh said there were 268 self-harming incidents within New Zealand prisons over a six-year period to 2021, and 39 deaths.
In 2018 to 2019 there were eight recorded instances of self-harm at Waikeria alone.
King acknowledged self-harm and suicide were much higher in the incarcerated than in the community.
Hesketh asked whether the risk questionnaire should prompt inmates for a copy of any relevant reports but King said he had been told the questions and assessment process was gold standard globally.
When questioned by counsel Genevieve Haszard about what training he had in undertaking risk assessments, King said he had one day's training eight years earlier and half a day in suicide assessment training every two years after that.
However, King also took new inmates aside, telling them not to tell others of the charges they were facing, and of their right to seek help if they felt at risk of assault or generally unsafe in prison at any time.
"If something happens to you, if your cellmate is picking on you or you're getting stood over in the yard or by your cellmate, don't feel like you can't be a 'nark' because of the repercussions," King said he told inmates.
"You can talk to staff and we can move you around or isolate you."
Haszard pointed out King noted Whittal-Bell had no family support and she asked whether there should be space in the risk assessment summary to note if a prisoner should be checked on by the officer in charge of their unit.
The court heard the information was recorded in the Integrated Offender Management System (IOMS) and the next Corrections officer who accessed the summary could see those details.
In the case of Whittal-Bell, King did not recommend he needed the Intervention Support Unit (ISU), a separate unit for at-risk prisoners.
King said he never rushed an assessment but he largely had to rely on prisoners to tell him the truth.
He said "masking behaviour" was hard to detect and prisoners were "pretty good at it".
Regular prisoners would game the system, King said.
If they didn't want to go to ISU where they were monitored, they would "lie through their teeth".
King agreed the risk for an inmate could change at any time.
Prison nurse Sherill Lawrence, who assessed Whittal-Bell minutes after King, told the inquest she marked the inmate as semi-urgent during his triage, which meant he should be assessed again within two weeks.
She noted lacerations and scars, which he explained as self-harming due to his ADHD medication, but that he had no thoughts of hurting himself.
"He was quite calm, showed no signs of agitation. His demeanour seemed settled."
Lawrence said her notes outlining the self-harm could only be accessed by medical staff and not the prison guard assigned to Whittal-Bell's unit.
She could not explain why King had not told her of Whittal-Bell's attempt on his own life.
She also did not know why she was not made aware of Whittal-Bell's other mental health diagnoses.
Lawrence said the system could be improved with more resourcing and time because staff were "under the pump to push people through".
Waikeria Prison nurse Trish Herrick said she requested mental health medical records for Whittal-Bell and then went on secondment to another prison.
Hesketh said it was unclear whether the prison received the records and it appeared there was no specific person tasked with following up the request, leaving a gap in the system.
The inquest is set down for three days and will hear from 10 witnesses.