Coroner recommends prison design changes
Hurikino Luke died in custody last year (file pic)
By Dan Satherley
A coroner has recommended changes to the design of future prisons following the death of a prisoner being held on remand.
Hurikino Luke was found dead in his cell at Christchurch Men's Prison on the morning of January 11, 2011. The coroner has ruled that he died after hanging himself from an exposed heating pipe near the ceiling.
Luke, 26, had been arrested on the morning of Friday, January 7, and charged with two counts of contravening a protection order.
Before being transported to Christchurch District Court that afternoon, police had concluded he was not considered at risk of self-harm, despite a suicide alert in the police system from 2006.
The arresting officer, Constable Michael Kneebone said that following his arrest, Luke was "obviously upset but not overly so".
Luke was remanded in custody, scheduled to reappear in the Christchurch District Court on January 11. When he arrived at the prison around 4:40pm, he was assessed by a Corrections officer and a nurse, and given the standard induction speech for inmates going into the high-security Kauri Unit, where he would be placed with a cellmate.
According to nurse Kim Read, Luke was "easily engaging in conversation. Good eye contact. Denies thoughts of self-harm. Can assure me his safety at this present time."
Custodial assessor Peter Scott said he had not been informed of the 2006 alert, which included references to "wanting to cut wrists", "continually banging head in cell" and "continuing to self-harm in presence of doctor", but even if he had, he told the coroner it would not have changed his assessment, as he seemed "calm and rational with his thoughts and behaviour", and was in a "happy mood".
Luke had told Mr Scott about how in 2002 he had cut his wrists and seen a professional in regards to emotional problems. Mr Scott however said Luke told him he had no concerns about being in prison and would be "all good". He did not appear to be under the influence of drugs or alcohol, but had used cannabis the previous evening.
On January 10, Luke was transferred to a single cell in the Te Ahuhu Unit, which was normally only used to house prisoners considered "low risk" from a security perspective, and "towards the pathway of being released".
"In practice these would be prisoners at low risk to self as well as low security risk," said Coroner Richard McElrea.
However since the September 2010 earthquake, exceptional circumstances meant the unit was temporarily being used to house other prisoners.
"In this case the prisoner was in the early period of imprisonment and was only placed in the unit because of exigencies arising from the Canterbury earthquakes," said the coroner.
As Christchurch Men's Prison is back to being fully operational, this situation no longer applies.
Corrections officer Daniel Goddard said nothing Luke did or said was out of the ordinary. In fact, Luke had told him he was "pretty stoked" about the transfer, as his cousin was being held at the Te Ahuhu Unit.
Mr Goddard last spoke to Luke around 7:45am, asking if he wanted anything. Luke replied, "No, I'm good, boss."
That night, Luke spoke to a prisoner in an adjoining cell for around 30 to 40 minutes. His neighbour loaned him a cigarette lighter and two books – one of which was called A Fine Night For Dying. Luke began reading, and called out that a person had hanged himself.
Around 10:30pm, the conversation ended. The neighbour said Luke had seemed "fine" with "no hint of anything". Another prisoner who overheard the conversation said Luke "did not come across as broken or depressed".
The next morning, around 8am, Luke was found dead, hanging from the pipe above..
The prisoner he'd been talking to said after they'd finished their conversation, felt a "bit of a tremor", and later realised it might have been Luke "doing his thing".
The prisoner who overheard the conversation backed this up, saying he heard a "single bang" from Luke's cell some time before midnight.
The cells in the Te Ahuhu Unit had pipes mounted to the wall, which provided heat by circulating hot water. Not unique to Christchurch Men's Prison, the pipes had been noted by the Department of Corrections in the past as a suicide risk.
Corrections had considered different methods of eliminating the risk – for example, lowering the pipes (at a cost of $11 million), concealing the pipes ($6.3 million, but creating a hiding place for banned items) or installing new heating systems altogether ($30 to $40 million).
Otago Corrections Facility manager Jack Harrison however said that prisoners can find "many" ways of harming themselves, so Corrections' approach is "active management of prisoners – identifying those who do pose a risk to themselves, and the availability of at-risk cells for those specifically identified as at-risk". At the time of Luke's death, this approach was applied on a pilot basis at Christchurch Men's Prison.
The Te Ahuhu Unit, built in 2005, was generally only used for low-risk prisoners, so the pipes generally weren't considered a suicide risk, and were designed to provide a consistent heat across the unit's 60 cells. Prisoners could also use the pipes to dry off clothes they'd washed.
Coroner McElrea said this meant despite their possible use in suicide attempts, the pipes at Te Ahuhu were an acceptable design choice, though future prisons should avoid exposed piping.
The coroner said the case highlights just because a prisoner is assessed as being "not at risk of self-harm… does not equate to that prisoner being at low risk of self-harm", as Luke was only in the "early period of imprisonment".
He ruled that "consideration be given to only prisoners considered at low risk of self-harm and who are 'towards the pathway of being released' be placed in low security units with design features such as exposed piping".
"Hurikino Luke had been in the prison only a matter of days, he had a history of violence, and some serious self-harm incidents in custody in the past," said Coroner McElrea. "He was a remand prisoner being placed in an environment that would not in normal circumstances apply."
He also recommended reviewing the weight prison staff should place on historical at-risk information relating to prisoners.
A secondary issue to arise from the case was the timing of cell checks by prison staff.
The log book shows checks were carried out at 12:05am, 2:05am and 4:05am. All three of the checks "failed to establish the prisoner… was in a compromised position and in fact dead.
"This occurred because he was apparently lying on his bed, and the extent of the check was to establish his presence in the cell subject to noticing anything untoward."
Mr Goddard described the process he called "body checks" as thus: "You look into the cell to see if you have a body inside the cell. You are not looking for a response from the prisoner."
Prison inspector Trevor Longmuir told the inquiry, "that if a prisoner is in that cell and there is nothing untoward, if you pull the curtain, put a torch through and you see somebody suspended in the air obviously that is going to cause an emergency situation… you are physically just looking for a person in a bed, nothing untoward and that is it."
The coroner ruled the checks were in breach of Prison Service Operations Manual requirements, as they are meant to be carried out at irregular intervals, no longer than two hours apart.
He did not believe this contributed to Luke's death, however.
"Whether a more extensive check at an irregular interval would have prevented the death of Hurikino Luke would be a matter of chance," he said.
He ruled that the prisoner check policy at Christchurch Men's Prison should be reviewed "to better ensure the welfare of prisoners".