Summary of the Operational Review into a Breach of Security at a Christchurch Men’s Prison Unit


On Tuesday 21 June 2016, a prisoner was escorted from the Receiving Office to a unit at Christchurch Men’s Prison by the Escort Runner.  The prisoner was secured in the unit yard and his file was passed to the unit custodial staff.  The prisoner remained in the unit yard until approximately 7.00pm on 21 June 2016.

As a result of this incident an Operational Review was commissioned by the Southern Regional Commissioner, Ben Clark.  The Principal Custodial Adviser and Practice Manager Custodial undertook an Operational Review into the circumstances relating to a prisoner’s management from the point of his transfer between units at approximately 9.30am until his eventual discovery in a unit exercise yard at approximately 7:00pm on 21 June 2016. This review was conducted under terms of reference approved by the Southern Regional Commissioner.

The Operational Review Report (the Report), was prepared following an examination of all available documentation relating to the incident, including Unit Muster records, Yard Muster records, and photographic prisoner Muster Reports.  A visual examination of the unit and the yard were also completed to aid the preparation of the Report.  The Report authors also interviewed relevant managers and staff involved with the management of the prisoner on 21 June 2016.


At approximately 9.30am on Tuesday 21 June 2016, a prisoner was escorted by the Escort Runner from the Receiving Office to a unit.  On communicating with the Unit Control Room the Escort Runner escorted the prisoner to the yard area of the unit and met with a unit officer.  The Escort Runner handed the prisoner’s custody file to the unit officer and assisted with placing the prisoner into a yard.

Throughout the morning of 21 June 2016, no one from the unit came to see the prisoner or conduct the unit induction process for his entry into the unit.  At some point after 11.30am the prisoner called out to the Unit Sentry notifying him that he hadn’t received his lunch.  The sentry acknowledged the prisoner’s request but no lunch was arranged for him.

At 2.00pm a General Random Muster for all of Christchurch Men’s Prison was requested by the Central Master Control Room.  The unit staff undertook the unit muster, however did not note the absence of the prisoner who remained unaccounted for in the yard, nor was the muster sheet signed off correctly.  At approximately 4.15pm all unit prisoners were locked in their cells and fed their evening meal.  The Senior Corrections Officer (SCO) and another Corrections Officer completed a face to name muster check at 4.15pm during lock up.  The SCO incorrectly believed only one prisoner was expected to be in the cell to which this prisoner was assigned.  Accordingly, muster was confirmed as correct, despite the prisoner remaining in the yard. The prisoner was still unaccounted for at this point. The prisoner did not receive his evening meal and he continued to go unaccounted for while he remained in the yard.

At approximately 7.00pm in the evening of 21 June 2016, Corrections staff were assisting the Health Unit nurse to conduct the medication rounds across the site.  As the staff were moving between units they heard the prisoner call out and he was discovered still locked in the yard.  At the time of his discovery in the yard, the prisoner had superficial wounds on his ankle and knee as a result of self harm.

The prisoner was taken to the Health Unit where his wounds were assessed and treated.  He was provided with two hot meals from the kitchen and relocated to another unit.  No At Risk Review Report was completed to assess whether the prisoner may have been at risk of further self harm.

The incident was reported to the Unit Residential Manager at approximately 7.15 pm and the following day the Residential Manager conducted a fact finding investigation into the incident.


Through a series of mistakes and omissions a prisoner was left in the yard of a unit from approximately 9.45am to 7.00pm. He didn’t receive his lunch or his evening meal, and was not accounted for as part of the final lock-up.

There were numerous control points throughout the day that should have alerted or reminded staff that the prisoner was in the yard.

Staff did not correctly complete the muster at 2.00pm. The final lockup face to name muster was not completed to the required standard.

When the prisoner was discovered with superficial self inflicted wounds, he did not have his risk status reviewed.  He was, however, provided with immediate medical attention and two hot meals.

None of the staff involved in his discovery in the yard entered incident reports.  It was nine days after the event that the National Incident Line was informed.


Following the Operational Review into this incident, 13 recommendations were made to the Prison Director of Christchurch Men’s Prison.  These recommendations include that:

  • The Prison Director reviews:
    • the prisoner transition methods on site at Christchurch Men’s Prison;
    • the placement of prisoners within the high security accommodation units at Christchurch Men’s Prison, with a focus on finding solutions for more appropriate placement of the increasing number of remand prisoners;
    • the staff induction process for staff that are reassigned or redeployed to any unit that is not their usual placement.  They need to be informed as to the routines of the new unit;
    • the unit desk files at Christchurch Men’s Prison;
    • how prisoner cell and location checks are being completed;
    • the method  by which staff provide meals to the prisoner population; and
    • the employment of prisoners holding influential positions within Christchurch Men’s Prison such as the kit locker, servery workers and other internal employment ensuring that they are the correct prisoners in these roles and that all prisoners are receiving their appropriate entitlements.
  • The Prison Director is to provide assurances that:
    • facility searches are being conducted in accordance with the requirements;
    • all staff and managers are aware of their obligations regarding incident reporting in accordance with the Prison Operations Manual;
    • musters are being completed in accordance with the Prison Operations Manual;
    • facility searches are being conducted in accordance with the requirements of the Prison Operations Manual;
    • all staff and managers are aware of their obligations in regards to incident reporting in accordance with Prison Operations Manual;
    • all staff and managers are aware of their obligations in regards to conducting risk reviews in accordance with Prison Operations Manual; and
    • the application of the Razor Policy at Christchurch Men’s Prison is compliant with Prison Operations Manual.
  • consideration be given to whether the capital works already planned for the Matai Yards can be prioritised.