A coroner has identified substantial shortcomings in the care and restraint procedures that preceded the death of a mentally ill man pepper-sprayed at Mt Eden Corrections Facility in April 2022.

Caleb Moefa'auo, 26, went into cardiac arrest in his cell and died following a confrontation with guards over a bathroom towel. Coroner Heather McKenzie released her findings on Wednesday.

The officer who deployed the spray was charged with assault but acquitted by a jury.

Failure to share mental health information

Moefa'auo had been diagnosed with schizoaffective disorder and admitted guilt to aggravated assault and shoplifting in June 2021. He was transferred to Mt Eden in December 2021 following an alleged assault on another patient at a residential mental health facility. He was placed in the prison's Intervention and Support Unit after being found at risk of self-harm.

McKenzie concluded that staff responding to the April 2022 incident had no knowledge of his psychiatric condition and may have responded differently with that information. The majority of Intervention and Support Unit officers had not encountered Moefa'auo before 4 or 5 April 2022 and had no understanding of his typical behaviour.

The coroner determined his mental illness was a probable factor in the incident, noting the contrast with his ordinarily polite and engaged conduct.

The officer who used the pepper spray told the inquest: "It wasn't until after his death that I found out that he had come from an acute mental health ward, hadn't been taking his medication, and had not slept the previous night".

"Looking back now, I think I would have approached him differently if I had known more about him. The more information about the people we are looking after, the better decisions we can make", the officer said.

Inadequate mental health management

McKenzie said ["the care provided to Caleb by the [Forensic Prison Team] was not the standard of care that the FPT generally provided"](https://www.rnz.co.nz/news/crime-and-justice/618545/coroner-releases-findings-into-caleb-moefa-auo-s-death-family-still-waiting-for-apology).

The coroner said "the FPT did not sufficiently actively manage Caleb's mental health between December 2021 and April 2022".

Moefa'auo had been refusing to take prescribed medications olanzapine and aripiprazole, though the coroner could not establish conclusively whether this affected his mental state, as testing showed olanzapine levels consistent with regular use.

McKenzie determined there had been prior opportunities to detect and address what appeared to be a deterioration in his condition when he returned to the ISU in April 2022. Covid-19 settings made a material impact on staff ability to provide mental health care to prisoners, affecting both workforce numbers and face-to-face prisoner engagement.

Use of force criticised

The incident began when Moefa'auo took a fourth towel after showering and drying himself with three. An acting senior corrections officer approached him with a can of pepper spray and directed him to hand over the towel, which Moefa'auo did.

When told to kneel and then starting to rise, Moefa'auo was shouted at and pepper-sprayed. He was returned to his cell where he went into cardiac arrest and died despite CPR.

McKenzie said "the officers did not adequately and continually assess whether less restrictive responses to Caleb's behaviour were available and monitor his physical and psychological well-being".

She said "there was inadequate ongoing consideration given to whether the continuation of use of force was necessary, reasonable, and proportionate".

Moefa'auo stated he could not breathe but the comments were not responded to sufficiently. The coroner determined the cause of death was prone restraint cardiac arrest associated with cardiomegaly.

Recommendations for change

McKenzie recommended that daily and handover briefings to ISU staff include an overview of each prisoner to ensure awareness of current issues and recent occurrences.

She recommended training include reminders to officers to take into account a prisoner's mental health when applying threat, exposure, necessity and response principles.

The coroner said ["[I recommend] there be specialist in-depth training for staff working in the ISU including any unit-specific mental health training to increase awareness of the impact that mental health might have on an ISU prisoner's behaviour and risk"](https://www.rnz.co.nz/news/crime-and-justice/618545/coroner-releases-findings-into-caleb-moefa-auo-s-death-family-still-waiting-for-apology).

McKenzie also recommended Corrections review its communication methods, including document management systems, to ensure ISU officers receive real-time information on prisoners.

Family still awaiting apology

Moefa'auo's mother Justine Lauese said the family has not received an apology in the four years since her son's death.

"Throughout the whole process we have never received an apology or heard anyone say sorry", she said.

Lauese said "the findings are more about systemic change, so we're not completely happy about that, because we believe it's still not over".

She said "we will be carefully considering our next steps including what further avenues may now be available to us to ensure that accountability for Caleb, as a person's passing, is met".

Lauese said the recommendations are a good start if implemented and wants assurance that Corrections will follow through with monitoring and embedding them in processes.

Corrections accepts findings

Corrections acknowledged the use of pepper spray was not appropriate and accepted all the coroner's findings and recommendations.

Chief mental health and addictions officer Emma Gardner said Corrections had improved handovers between staff in the ISU, as well as its tactical options training and use of force.

Gardner said parts of the recommendations should have already been in place and said Corrections had made a number of changes addressing the coroner's recommendations. Mental health teams in prisons were established in 2018.