Coroner Cunninghame is overseeing the inquest at Dunedin District Court. Photo: RNZ / Nate McKinnon
A Dunedin-based coroner is investigating whether the death of a prisoner was preventable after he was assaulted and suffered a severe head injury, dying more than a year later.
Grant Steven Bowden, 47, was struck by a fellow prisoner in the exercise yard on 3 November in 2017, falling backwards, hitting his head on the concrete and knocking him unconscious.
He was taken to Dunedin Hospital where medical staff saved his life by preventing his swollen brain from being crushed against his skull and he was discharged after 12 days.
The incident resulted in a traumatic brain injury and severe disability that meant he could not swallow liquids or food.
He was transferred to a facility in West Auckland in May 2018.
Bowden died of multiple organ system failure at Auckland's Waitākere Hospital in December in 2018 after developing a chest infection.
Senior forensic pathologist, Dr Martin Sage, told the inquest the brain injury was extremely severe and he was susceptible to aspiration pneumonia due to his disability.
One of his physicians at the time described his outlook as dismal, he said.
"In my view, there is an incontrovertible causal link between the head injuries he sustained and his eventual death from complications with aspiration pneumonia, but they could be most likely a direct consequence of his swallowing disability engendered by his head injuries."
Coroner Cunninghame is overseeing the inquest at Dunedin District Court, and said she would review the cause and circumstances of his death.
"Did Otago Corrections Facility custodial staff comply with their duties, legislative policy and procedural to Mr Bowden? Did OCF health staff adequately assess, treat and manage Mr Bowden?"
A few weeks before the incident, Bowden was remanded in custody on burglary charges.
He suffered from schizophrenia and was initially placed in the at-risk unit at the prison, but requested to be moved into the remand unit.
On the day of the incident, CCTV footage showed Bowden and fellow prisoner Nyal Heke standing near the exercise yard fence before punches were thrown.
Other prisoners continued to do push ups as the two fought, moving into a dark corner and emerging separately.
The fight resumed as some watched on. There were kicks and punches with little landing until one swing from Heke and Bowden dropped to the ground.
Not long after, Heke appeared to roll Bowden into the recovery position.
The inmates came together, talking as they started to leave the yard with Bowden laying unconscious in the background.
Footage from a body camera showed blood pooled near his head as staff assessed and treated him.
Following the incident, Heke pleaded guilty to causing grievous bodily harm with intent to injure and had 15 months added to his prison term.
His counsel Adriana Pinnock said her client had complained that Bowden had sought to pick a fight with him.
On the day of the incident, she said he only struck Bowden after he was kicked and made no excuses for his actions.
He was due to give evidence at the inquest on Monday.
The family's counsel, Owen Jacques, read out a statement from his family, describing him as making up the fabric of their family.
"Grant was dealt a pretty terrible hand. To others, he may have been though of as unlucky or as a statistic. But to us, he is, or was, a son, brother, uncle, cousin and friend."
The inquest is scheduled until 27 January.