Prisoner waited four months for mental health help before suicide - coroner

A Rimutaka Prison inmate who killed himself in his cell in 2020 had been waiting for four months to be seen by mental health services.

Jessie Tiwai James-McDonald, 27, a father-of-three, was found dead at about 10.30pm on 19 May, 2020.

In a finding released on Friday, Coroner Mary-Anne Borrowdale said the Covid-19 lockdown had worsened his access to "already overstretched" forensic mental health services.

"I note that the Office of the Inspectorate found that there were more than three times the number of suspected prison suicides in the 15 months after March 2020, when the lockdowns began, than in the previous 15 month period - a statistic of obvious concern."

James-McDonald reported having felt depressed since the age of eight.

First sent to a youth justice facility at the age of 14, he had a history of childhood trauma, drug and alcohol abuse, depression and ADHD.

He was assessed by a nurse on arrival at Waikeria Prison on 3 January 2020, and prescribed medication for anxiety and depression.

The nurse said he should be considered "at risk of self-harm" but she was overruled, possibly because the prisoner himself did not want to go into the high-risk unit.

Later that month, on 21 January, the prison health team referred him to the Central Regional Forensic Mental Health Service for depression and anxiety.

It noted his history of ADHD, sleeping problems, social anxiety, and depression, but said he denied any thoughts of self-harm or of harming others.

The referral was accepted the next day, noting he would be seen by a justice liaison nurse "at the earliest convenience".

However, on the day the referral was made (21 January) James-McDonald was transferred to Rimutaka Prison because of overcrowding.

A nurse who assessed him there noted the referral to forensic services, but found he was "engaging well, polite, and settled".

He had regular consultations with health staff to have wounds dressed and sleep treatments organised, but continued to deny having any thoughts of self-harm.

A follow-up referral was made to the forensic service on 16 March, for depression and lack of sleep.

On 18 May 2020 - the day before his death - James-McDonald pleaded guilty to 11 criminal offences, including resisting and assaulting police, robbery, assault, and kidnapping.

Mental health services shut out of prison during lockdown

The forensic service's lead clinician, Dr Caroline Holmes, told the coroner that it was not considered "an essential health service" during the Covid-19 Level 4 lockdown.

She said a great deal of effort was spent in trying - but failing - to set up a reliable audiovisual link (AVL) into Rimutaka Prison for the purpose of holding psychiatric clinics.

From 1 April, they were able to do telephone conferences with the Rimutaka Prison health team to discuss "prisoners of concern", but James-McDonald was not among them.

At the time, there were 10 people in the prison's Intervention and Support Unit (ISU) waiting for hospital admission, and other prisoners of "acute psychiatric concern", Holmes said.

James-McDonald's referral "did not stand out as being urgent, as there were no concerns about self-harm".

On 14 April 2020 a second follow-up referral was sent to the forensic service, regarding James-McDonald's lack of sleep.

The country was moved down to Alert Level 3 on 27 April 2020, where it remained at the time of his death.

James-McDonald was seen by the health service on 2 May 2020, for the final time, for sinus pain.

In the previous two weeks, he had had four other consultations for sleep problems, anxiety and grief.

However, the coroner noted that neither health staff, nor either of his former cellmates (one of whom had known him for a decade) had any sense that he was considering harming himself.

On 12 May, James-McDonald appeared in the Tauranga District Court by AVL and received a sentence indication of three years, nine months' imprisonment.

His fellow inmates said this was longer than he had expected, but prison staff said he did not appear to react badly.

On 18 May he asked staff if he could be given a prison job that another inmate had left, and was told he would be added to the waitlist.

Later that day, James-McDonald again appeared in Court by AVL and pleaded guilty to the charges. A report was ordered for sentencing on 3 July but there was no risk assessment at the time.

Following his death, the Prison Inspectorate carried out an investigation, which found:

• James-McDonald had not been risk screened by custodial and health staff following his two recent Court AVL appearances
• He had not been reviewed by the forensic service between its acceptance of his referral on 22 January and his death on 19 May 2020.

The Inspectorate recommended:

• A high-level review of the decisions process when assessors cannot agree on a risk assessment
• Rimutaka Prison staff be made aware of the requirement for a risk assessment on prisoners who return from court, including from AVL hearings, or who have a change of custodial status
• Corrections review the agreement with the forensic service for timeframes to respond to non-urgent referrals, and Rimutaka's process for tracking referrals.

Health NZ's Mental Health, Addictions and Intellectual Disability Service carried out its own review into James-McDonald's death in March 2022, which found:

• The forensic team faced challenges in the referrals it received with higher numbers and long wait times
• The screening tool used by prison staff produced "many false positives", leading to a high number of inappropriate referrals
• The prison health team lacked staff or capacity to further triage prisoners at risk of mental distress
• The Covid-19 lockdown meant forensic staff were deemed "non-essential" and could not see prisoners at Rimutaka.

"The reviewers noted that the initial forensic service response to the referral - advice

of acceptance - had been sent very quickly.

"After this, the service made no response to the prison, including no response to the 16 March and 14 April follow-up emails.

"Mr James-McDonald had been on a waitlist for four months when he died. He was,

during this time, listed for discussion at regular forensics' multi-disciplinary meetings, but due to insufficient allocated time was not discussed."

The reviewers recommended that mental health services work with the prison health team on ways to appropriately triage referrals and develop a standardised process "with timeframes and accountability at each stage".

A process should be developed to manage all those on the forensic service waitlist "so that they do not fall through the cracks in times of heavy demand".

'Overwhelming' number of referrals - psychiatrist

The coroner said she was satisfied with Corrections' response to the earlier recommendations and its progress on implementing them.

It already had an escalation pathway in place when staff disagreed over prisoner risk, and agreed "a cautious approach should be taken" in such cases, and had instructed Rimutaka Prison staff about the need to do risk assessments for prisoners following court appearances.

Dr Holmes advised there was already a standardised referrals process in place and in her view, the use of standardised documentation would not have prevented James-McDonald's death because he needed to be seen in person.

"Making an accurate triage decision on a patient who hasn't been seen, based on historical and often inaccurate referral information is problematic. The information we had did not suggest that he was at imminent risk of suicide.

"An earlier face to face clinical assessment for triage would have been an intervention which may have identified this and facilitated his access to medication sooner.

"Such an assessment was impossible at the time because of the overwhelming number of referrals and inability to get access to the prison."

Corrections had tightened its processes for tracking non-urgent forensic referrals, and had reclassified forensic as an "essential" service under Level 2, relaxing somewhat the permissions under which the forensic staff could enter the prisons and have face-to-face clinical contact with prisoners.

In September 2021, Corrections advised that there was now a mental health team operating inside Rimutaka Prison, improving the oversight and management of non-urgent referrals to the forensic service and support to prisoners while they were waiting to be seen.

'Life stressors' and unmet mental health needs behind death - Coroner

Coroner Borrowdale said in the search for reasons behind this death, "we can only speculate".

"However, it appears likely to me that the relevant life stressors for Mr James-McDonald were that he was anxious about his recent separation, concerned for his children, and had the previous day been convicted of offences for which he would serve a lengthy period of imprisonment."

She said his intercom call on 18 May seeking prison work showed he was focused on the future at that time.

"Despair must have overcome him after lock-up in the early afternoon on 19 May, imparting to his lethal actions a suggestion of impulsivity.

"Mr James-McDonald had not been overtly suicidal, but he had unmet mental health needs due to an outstanding referral to forensic services.

"Unquestionably, the restrictive prison environment resulting from the Covid-19 lockdown measures placed new pressure on already stretched forensic mental health services."

It was impossible to know how James-McDonald would have fared if lockdown had not happened, but he gave no sign he was thinking of ending his life, she wrote.

"Without an overt escalation in his mental unease, detectable to custodial or health staff, there was no basis for them to seek to escalate his care.

"I find that the impulsiveness of his actions prevented any opportunity for acute intervention."

The coroner did not have any further recommendations to make in addition to the reviews already undertaken "to learn the lessons of this death".

"I have outlined that the circumstances of Mr James-McDonald's suicide included the Covid-19 lockdown that worsened his access to the already overstretched forensic mental health services.

"The restrictive prison environment during the Covid-19 lockdowns has been the subject of further ex post assessment, including by the Office of the Inspectorate."

It was likely that the three-fold increase in suspected prison suicides in the 15 months following lockdown would be the subject of further scrutiny, she said.

Where to get help:

• Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason
• Lifeline: 0800 543 354 or text HELP to 4357
• Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends
• Depression Helpline: 0800 111 757 or text 4202
• Samaritans: 0800 726 666
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz
• What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds
• Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, and English.
• Rural Support Trust Helpline: 0800 787 254
• Healthline: 0800 611 116
• Rainbow Youth: (09) 376 4155
• OUTLine: 0800 688 5463
• Aoake te Rā bereaved by suicide service: or call 0800 000 053

If it is an emergency and you feel like you or someone else is at risk, call 111.

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