Prisoners say they asked corrections staff to relocate a mentally unwell inmate who was subsequently hit, critically injured, and died more than a year later.
Grant Steven Bowden, 47, was struck by inmate Nyal Heke, falling backward and hitting his head on the concrete during a fight at the Otago Corrections Facility on 3 November, 2017.
It resulted in a severe disability and he died in December 2018 following a chest infection.
A coronial inquest is underway in the Dunedin District Court to review his death, whether it was preventable and if prison and health staff adequately managed and supported him.
Grant Bowden was diagnosed with schizophrenia in his late teens, and had initially been placed in the at-risk unit at the prison before asking to be moved into the remand unit.
Nyal Heke told the inquest he asked a staff member for Bowden to be removed from the wing because he was trying to pick fights, and said he was trying to fight on the day of the incident.
He described the exercise yard as a hostile, and said quite a few fights had occurred there.
The corrections staff could see the yard and should have intervened when they saw signs of a fight, he said.
"He turned towards me with his hands up ready to hit me, so I squared off too, facing him. Grant Bowden then started moving around the yard, swinging his arms towards me and kicking out.
"I was trying not to hit him because I did not want to hurt him, so I avoided him for as long as could and I hoped that staff would see what was happening and intervene."
But they did not, and Nyal Heke said he started to get angry and wanted to get Bowden away from him.
Heke landed a punch that knocked him unconscious and he dropped to the ground.
"As soon as he hit the ground, I saw the blood coming out of his ears and his nose and eyes. His legs were shaking and stiff."
CCTV footage showed Heke putting Bowden into the recovery position, and Heke said it was a long wait for staff to arrive.
When asked whether he thought Bowden did not pose a physical threat, and if Bowden appeared uncoordinated and slow, Heke agreed, but said that even inexperienced or uncoordinated fighters could injure you.
Heke pleaded guilty to causing grievous bodily harm with intent to injure, and said he did so to avoid the risk of a trial.
He had 15 months added to his prison term.
"I still have nightmares about this," he said.
Fellow inmate Lucas Padget told the inquest Bowden's schizophrenia made him unpredictable.
He put other prisoners on edge and they wanted him to be moved out of their wing, Padget said.
"My memory of seeing Bowden is in a pool of blood and he had gone all white, sort of shaking on the ground.
"I can't recall what was going on before that, fighting in our yard was regular. It happened all the time so I would try to ignore it. But I heard the crack of Bowden's (head) hit the ground."
Corrections officer Rakesh Harrison was in the guard house at the corrections facility when the incident happened.
"While I was carrying out another task, I noticed some movement on the screens that caught my attention. It appeared that Mr Nyal Heke and Mr Bowden were doing what I'd describe as sparring. What I mean by this is that they were shadow boxing."
He described Bowden as uncoordinated, slow and was not landing any punches and Heke as dancing around like it was "a sport or a game".
"There was no clear threat."
Ater 30 seconds, he went to tell another staff member to check on the yard, Harrison said.
"When I'd looked back at the screen, Mr Bowden made another attempt at a punch. But Mr Heke stepped forward without any real provocation and punched Mr Bowden."
The fight escalated quite quickly from what appeared to be harmless behaviour to Bowden being knocked out, he said.
Former prisoner and witness Dain Wayne Manukau told the inquest Bowden should never have been in the prison unit as he was mentally unwell.
Bowden talked to and answered himself, he said.
The coronial inquest is scheduled to run until 27 January.