Their boy’s dead and family want answers
Young prisoner Vincent KuruNathan was choking on his Weet-Bix. He would probably have lived had it not been for a series of crucial delays by staff. Tony Wall reports.
It took a nurse nine minutes to travel 360 metres from Christchurch prison’s medical unit to the cell where a young inmate lay unconscious, one of numerous delays his family say could have contributed to his death.
Vincent Kuru-Nathan, 21, died at the prison on May 15 last year – apparently after bringing up his food and choking on it. Until now, there has been no publicity about the incident.
Kuru-Nathan’s mother and stepfather say they have been kept in the dark by Corrections and the coroner about what happened. They hadn’t seen a prisons inspectorate report on their boy’s death until shown it by Stuff.
The report, which was leaked to Stuff, also found there was a seven-minute delay in bringing a defibrillator to the cell because staff were confused about where it was kept.
Other findings include:
■ Guards initially did not take it seriously when prisoners shouted for help.
■ The on-duty nurse did not hear the emergency call because he wasn’t wearing his earpiece.
■ The medical vehicle could not be driven because its windscreen was frosted over.
Kuru-Nathan’s mother, Missy Kuru, says she feels more could have been done to save her son, but she does not want to apportion blame.
‘‘I’m not interested in pointing fingers . . . dead is dead, nothing is bringing him back. But [measures] need to be put in place so this doesn’t happen to anybody else.’’
Corrections says it has apologised to Kuru for the delay in providing her with the report and has arranged for her to be given a copy.
In the wake of Kuru-Nathan’s death it says it has also implemented a range of improvements, recommended in the inspectorate report, in all prisons.
The family want the coroner to open an inquest as they still have questions about how a young man could have died in such a way.
Kuru says she was told the case had been closed, but a spokesperson for coronial services says the file remains open and a decision on whether to hold a hearing has not yet been made.
Kuru-Nathan was serving a term of three years, five months’ imprisonment for offences that included a vicious late-night assault in his hometown of Ashburton which left a man with severe brain injuries.
He was in the prison’s low security Te Ahuhu unit and had begun an automotive course. He was due to be released about two months after he died and his family say they had building work lined up for him.
According to the inspectorate report, Kuru-Nathan went to the dining room at 7.12am on May 15 and returned to his cell with his breakfast.
At 7.48am he opened his cell door, put something in a rubbish bin, and closed the door. It was the last time he was seen alive.
At 8.12am a staff member in the Te Ahuhu guardroom called Kuru-Nathan on his cell’s intercom telling him to report for work, but got no response. A prisoner went to his cell and found him lying face-down and unresponsive and called out for staff.
Missy Kuru says she was told by a relative of the prisoner that there was dried Weet-Bix around her son’s mouth. A second prisoner who came to the cell alleged staff did not take him seriously when he called for help over the intercom.
A third prisoner arrived and found that Kuru-Nathan was still warm, but appeared ‘‘bluish’’ and he could not find a pulse. More prisoners arrived, placing him in the recovery position and calling out again for urgent help.
At 8.14am a senior corrections officer called the cell on the intercom, and said: ‘‘You need to go to medical.’’ The report states: ‘‘The [officer] appeared not to understand the seriousness of the situation.’’
Finally the automotive instructor and a custodial officer arrived and, with the prisoners, lifted Kuru-Nathan on to his bed to begin chest compressions. One of the prisoners began mouth-tomouth resuscitation.
The staff asked for a defibrillator to be brought to the cell but there was confusion about where it was and it took seven minutes to retrieve from the nearby guardroom.
They used the device but were unable to find a shockable heart rhythm. They kept up the chest compressions but Kuru-Nathan had turned blue. Staff had made an emergency medical call but the nurse at the medical unit was treating another prisoner, did not have his earpiece in and did not hear the call.
A guard went to alert the nurse. The report says the nurse’s emergency bag weighed 25kg so it was ‘‘impractical’’ to run the 360m to the cell. However, the medical car’s windscreen was frosted over and couldn’t be driven.
The nurse and guard decided to use a prison van instead. Before leaving, the guard loaded three prisoners who had been at the unit for medical treatment into the vehicle, planning to drop them back at their units. This caused a further delay of about two minutes.
The nurse arrived at KuruNathan’s cell about 8.24am, nine minutes after the emergency call. He noted that he appeared to have died but continued chest compressions until St John ambulance staff arrived at 8.41am.
Kuru-Nathan was pronounced dead at 8.48am. An autopsy found he died due to asphyxia resulting from aspiration of gastric contents.
Prisons inspector Rochelle Halligan recommended the prison director remind staff that attending an emergency call ‘‘requires a priority response’’, ensure the medical car is protected from the elements and driveable at all times, and remind staff of the locations of defibrillators.
Missy Kuru says it is clear from the report that staff ‘‘dropped the ball’’ and the explanation that the medical bag was too heavy to run with and the car was frosted over was a joke. ‘‘You’re talking about someone’s life. Just because it’s a prisoner it seems like . . . it’s just another prisoner, another
criminal, they don’t really matter. They’re entitled to rights just like everybody else.’’
However, she could understand how prison staff could become blase. ‘‘You hear 50 things a day and if you took every single one of them seriously . . . this just goes to show if you don’t look first, there might be that one time out of 100.
‘‘I would like to see policies put in place where this doesn’t happen again.
‘‘Why is there not a medical kit, portable defibrillators held in the cell? Why are we waiting for a nurse three rugby paddocks away? It’s just really basic, easy step-by-step things – first aid, initial reactions.’’
Ben Clark, regional commissioner of Corrections, says the department has implemented the recommendations in the report.
Staff are now reminded at morning briefings of the obligation to respond appropriately to emergency calls, including following radio protocols, and response actions had been included in monthly emergency exercises, he says.
De-icing spray and scrapers were put in all emergency vehicles following the incident.
All staff had been made aware of the locations of defibrillators and would receive reminder emails. Notices would be posted throughout prisons.
Clark says the prisoner who gave mouth-to-mouth will receive a commendation.
Kuru-Nathan’s family say they cannot understand why he did not press the emergency buzzer in his cell when he began choking – Clark confirmed all prison cells had them.
Clark says Corrections wrote to Missy Kuru in January telling her the report had been completed. It did not automatically send reports to families, but advised her how to request a copy.
‘‘We are now aware that this letter was not received.’’
He says Kuru contacted the coroner in May seeking an update. ‘‘Corrections was aware of this, and in hindsight should have proactively made contact with her.’’
The department had invited Kuru to meet the prison director to talk through her questions.
Kuru says she’d been asking for a report into her son’s death for more than a year and was given the ‘‘run-around’’ when she contacted the prison.
They appeared to be dealing with Vincent’s stepfather’s family, rather than her. ‘‘I was never contacted at all, they didn’t even know who I was.’’
Vincent was her second eldest child – her eldest, Tainui, is an actor and singer with the Modern Ma¯ ori Quartet.
Vincent got into trouble when he began drinking as a teen, she says. ‘‘He went from being a normal kid to . . . drinking, burglaries and fighting.’’
She fought to get him help, she says, but unless he was under Child, Youth and Family care, ‘‘they didn’t want to know’’.
‘‘All it would have taken was some anger management and drug and alcohol counselling.’’
Kuru says the longer prison sentence was good for Vincent, as he changed his mindset and was determined to get his life back on track. ‘‘He talked about going back to building, getting a partner and having a family.’’
The inspectorate report reveals that Kuru-Nathan had been seeing medical specialists while in prison for a painful lump in his chest caused by a hormone flux. He also had tests for an irregular pulse and suspected slow heartbeat.
In August 2015, a consultant at Christchurch Hospital recommended he start a sixmonth trial of Tamoxifen, the breast cancer drug.
But at a follow-up appointment in February 2016, the consultant expressed surprise the trial hadn’t started and asked that it begin immediately. The report said he took tamoxifen for over a year, rather than the six months recommended.
His family do not believe the drug trial was related to his death. Clark says management of his health concerns would be part of the information considered by the coroner.