Coroner releases findings into Caleb Moefa'auo's death, family still waiting for apology

The mother of a man who died after being pepper-sprayed in an Auckland prison says she is yet to receive an apology, four years after her son's death.

The coroner has released her findings into the death of Caleb Moefa'auo, who died after being pepper sprayed while in custody at Mt Eden Corrections Facility.

The officer responsible - who cannot be named - had been charged with assault, but was acquitted in a trial by jury.

Moefa'auo had been previously diagnosed with schizoaffective disorder, and was staying at a residential unit to support people with mental health issues after pleading guilty to aggravated assault and shoplifting in June 2021.

He was moved to Mt Eden in December 2021 after allegedly assaulting a fellow patient at the residential unit.

Moefa'auo was later placed in the prison's Intervention and Support Unit [ISU], when he was found to be at risk of self-harm.

The 26-year-old was pepper sprayed in April 2022, after a stand-off with guards over a bathroom towel.

He taken back to his cell, where he went into cardiac arrest and died shortly after.

Different approach

Coroner Heather McKenzie released her findings into Moefa'auo's death on Wednesday.

She found if officers had known of his mental health challenges they may have taken a different approach to how they interacted with him during the incident that led up to his death.

Coroner McKenzie recommended that daily and handover briefings to Corrections officers in the unit where Moefa'auo was held include an overview of each prisoner, so officers were aware of current issues and recent occurrences, and that training referencing threat, exposure, necessity, and response principles included a reminder to officers to take into account a prisoner's mental health.

"[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," she said.

The coroner also recommended Corrections review its methods of communication, including document management systems if needed, to ensure officers in the ISU were provided with real-time information on prisoners in the unit.

She ruled Moefa'auo's cause of death was prone restraint cardiac arrest associated with cardiomegaly - an enlargement of the heart.

"The care provided to Caleb by the [Forensic Prison Team] was not the standard of care that the FPT generally provided," McKenzie said.

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

McKenzie said it was likely Moefa'auo's mental health contributed to his actions, given "their contrast to his usual baseline presentation and behaviour".

"Caleb's usual, earlier interactions with prison staff were described as him being polite and engaged," she said.

"It is important to note that most ISU staff had not met Caleb before 4 or 5 April 2022 so could not compare the incident to his baseline behaviour."

It was possible Moefa'auo's continued refusal to take his medication, olanzapine and aripiprazole, impacted his mental health, but the Coroner said she could not make a definitive finding, as the approximate level of olanzapine in his system appeared consistent with normal use.

McKenzie said there were significant departures from relevant Corrections' polices at points.

"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 had initially been in the ISU before moving to various units. He was transferred back to the ISU in April 2022.

It was likely that when Moefa'auo was transferred back to the ISU he was experiencing a relapse of his mental illness, McKenzie said.

"There were earlier opportunities for Caleb's likely relapse to have been identified and managed however," she said.

McKenzie said Covid-19 settings had made a "material impact" on the ability of staff to provide mental health care to prisoners, both in the ISU and in other units.

"Deficiencies broadly related to the number of employed and available staff and their ability to engage with prisoners face-to-face," she said.

Moefa'afuo had made comments that he could not breathe, which were not responded to sufficiently, the coroner said.

Family to continue fight for justice

Moefa'auo's mother Justine Lauese told RNZ she was yet to receive an apology for what happened to her son.

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

"There was wording around it, but not an actual clear and concise apology, it's been difficult."

Lauese said they had only just begun their next fight for justice.

"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."

The recommendations from the coroner were a good start if implemented, she said.

"We would like assurance that Corrections plans to follow through with those recommendations, how is it going to be monitored and will it be embedded in their processes," Lauese said.

Corrections accepts findings, says pepper spray was inappropriate

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

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

She acknowledged parts of the recommendations should have already been in place, and said Corrections had made a number of changes, including those which addressed the coroner's recommendations,

"I think it's one of those things where you learn as you're going along," Gardner said.

"Our mental health teams were established in 2018, and as we've continued to improve and enhance those services and roll them out more nationally, we have been evolving, iterating and continually improving the ways that we do things."

Gardner described what happened as tragic.

"We are taking this really, really seriously, obviously this is a very tragic event and we do not want to see that occur again," she said.

"I am confident that we've made a number of really significant improvements, both in terms of how we share information but also how we manage situations like this going into the future."

What happened to Caleb Moefa'auo

The first phase of the Coronial Inquest heard from counsel assisting the coroner Rebekah Jordan, who outlined the series of events leading up to Moefa'auo's death.

He had taken a shower that day, and used three towels to dry himself.

After taking a fourth, an acting senior corrections officer approached him, holding a can of pepper spray.

Moefa'auo was told to pass the towel to another officer, which he did, before being directed to get on his knees.

When Moefa'auo began to rise, the acting senior officer shouted at him, before spraying him.

He was taken back to his cell where he stopped responding.

CPR was started, but moments later, Caleb Moefa'auo was dead.

The officer who sprayed Moefa'auo told the second phase of the inquest, that the death haunted them.

"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," they said.

"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."

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