In a report released today, Coroner Amelia Steel was critical of the prison and the Department of Corrections for failing to act on an issue they knew put prisoners at risk.
“The continued exposure of prisoners to known …risks is unacceptable.”
Strange, 30, had attempted suicide in the weeks and months before his death and had been in and out of the prison’s intervention and support unit (ISU).
He was released from the ISU a day before his death on August 4, 2022.
Coroner Steel held an inquest into his death earlier this year that found errors led to Strange slipping through the cracks.
Strange was taken into custody at Invercargill Prison on April 14, 2022.
He was a remand convicted prisoner, having been charged with 22 offences including driving, property and firearm offences. Before this, he had been incarcerated 11 other times and received four sentences of imprisonment.
While on remand, Strange became increasingly distressed by the prospect of a lengthy custodial sentence and its impact on his relationship with his partner.
His partner ended the relationship as he faced eight years behind bars, but they remained close.
On June 4, 2022, Strange attempted suicide in his cell but was discovered by staff.
He was assessed as at risk of self-harm and relocated to the ISU until June 17, 2022.
Strange was assessed as at risk of self-harm three more times and relocated to the ISU between June 21 and August 3, 2022.
On the day of his death, he was no longer in the ISU but his normal cell in the South Unit.
On August 4, 2022, another prisoner was cleaning cell windows. At 11.03am he opened Strange’s cell window flap to clean the glass and saw him unresponsive.
Prison officers were called for help and began CPR but he could not be revived. Police ruled there were no suspicious circumstances to his death.
One prison officer was not aware Strange had broken up with his partner, but knew he was infatuated with her and gave evidence that a break-up is a change of circumstance that would be noted and followed up with the prisoner.
A former health centre manager at the prison described Strange as being “a really nice easy person to talk to”.
Nuku Strange died in Invercargill Prison in August 2022.
She said it was concerning that Strange had four admissions to ISU in quick succession and described care in ISU as preventive, not therapeutic.
She described it as “a sterile, uncomfortable place with a lack of socialisation”.
Following his death, she reviewed her decision-making regarding his risk on August 3, 2022 and maintained that the best thing for him at that time was to be released from the ISU and return to his unit.
The manager agreed that Strange could have said all the right things that day because he wanted to get back to the unit to put into effect the plan to end his life, something that was extremely difficult to do in ISU.
Since his death, daily Multi Disciplinary Team (MDT) meetings involving custodial and mental health staff had been implemented at the prison, the manager said.
The MDT meetings share information about individuals to get a more person-centric view and create a care plan for their exit from ISU. When somebody leaves ISU they receive welfare checks within the primary health care team.
Dr Maxwell Panckhurst, forensic psychiatrist, reviewed The Office of the Inspectorate Report completed after Strange’s death.
The Inspectorate identified deficiencies in the accuracy and completeness of recorded information. There were no active self-harm or suicide risk alerts in his health file.
The Inspectorate concluded that these documentation gaps limited the effectiveness of the assessments in information care planning and risk management.
Panckhurst’s overall opinion was that the mental health care and risk management provided to Strange during his time in custody were generally within accepted clinical standards for a custodial setting.
However, there were “specific procedural departures from Corrections policy at key points in Mr Strange’s custodial care”.
Prisoner died six years earlier
In April 2016, Alexander David Eric Sydney Jarman died in Invercargill Men’s Prison by suicide. Jarman and Strange’s deaths had similarities.
An inquest into his death resulted in Deputy Chief Coroner AnnaTutton recommending Corrections prioritise funding to prevent a known risk area in the cells, the exact details of which are suppressed.
“However, eight years after Mr Jarman’s death, Nuku essentially used the same method to end his own life in Invercargill Prison,” Coroner Steel said.
Nukuroa Strange, pictured with his mother Kerry Pink, as a toddler.
“The Department of Corrections failed to act with urgency to mitigate this known risk. It has failed to fund the remediation … with sufficient urgency to address the known risk.”
Steel visited the prison as part of her inquest and found work was still required to mitigate obvious areas of concern at Invercargill Prison.
“The programme of work is disparate and underfunded and remains a substantial risk for the prison population, especially those with mental health issues and those that work within the prison estate.”
Recommendations aim to protect prisoners
As part of her report, Coroner Steel provided recommendations to the prison and Corrections.
To the Office of the Inspectorate, she recommended the Prison Director identify options to remove risk areas, remind all staff of the requirements to conduct review risk assessments and remind custodial staff of the requirements to interview a prisoner when conducting a review risk assessment.
She recommended the Health Centre manager review the use of mental health assessment tools for documenting wellbeing assessments, particularly when undertaking assessments in the ISU, review how emergency equipment is transported to an incident to ensure there are no delays in providing care, and remind health staff that a record should be made of all instances of medication administration, even if the patient declines the medication.
She recommended Corrections consider the merit of Review Risk Assessments, increase the frequency of custodial and health staff training focused on suicide risk and develop transitional placement units within prisons to allow for therapeutic intervention for prisoners transitioning from ISU to prison units.
She also recommended Corrections employ more trained mental health staff to support the wellbeing of prisoners and revise the scope of a Remediation Programme so that it is responsible for all identified (risk) remediation work across the prison estate and that it is appropriately funded to complete its wider scope.
Emma Gardner, chief mental health and addictions officer, said Correctionswas committed to doing everything it can to prevent deaths in custody.
“Corrections received the final findings from the Coroner on July 22 and is working through the recommendations but has made a number of changes in recent years to better support prisoners with their mental health and wellbeing.”
It had recently released its refreshed Suicide Prevention and Postvention Action plan 2026-2029, with a key action within the plan being to ensure its infrastructure was being progressively upgraded to ensure it was as safe as possible.
“Corrections has a significant focus on the safe and humane management of prisoners and the application of best policy and procedures to minimise the risk of self-harm and death.
“We continue to address safety issues across the estate through both wider prison and cell design, network planning, current programmes of work and through day-to-day operational works.”
Pink said she was happy Corrections would finally do something to stop a similar incident from happening again.
Pink and a friend are looking to hold a suicide awareness event in Invercargill in September to raise awareness of the issue.
“I don’t want any mother or family to go through what we have gone through as it has changed me and my family.”
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.
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