Now Coroner Bruce Hesketh has released his findings into Kohiti’s death, and issued recommendations about the release of long-term prisoners.
Kohiti was released to a residence set up for parolees, run by Anglican Action Manaaki Atu, and he was required to wear an ankle bracelet.
He lived in a single-person unit, and was observed to have “kept to himself” at the facility, with his room kept tidy, and he followed a “set routine”.
His supervisor at the facility said Kohiti didn’t display any health problems, except that he took pain medication for issues related to his lumbar spine.
The findings said that in the two months he was at the facility, he didn’t receive any visits from whānau or friends; his closest support had been his mother, who had passed away.
In the weeks before his death, he made comments to both his supervisor, and to probations staff, about wanting to go back to prison.
On Monday, July 28, a First Security officer arrived to check on Kohiti after his ankle bracelet tracking showed he had been “inactive for a long period of time”.
Kohiti was found at his unit, paramedics were called, and he was pronounced dead.
The last time his supervisor had seen him was on Friday, July 25, three days earlier. He had left a note on the kitchen table.
The coroner received information from Tongariro Prison to indicate that Kohiti had been considered a “responsible inmate”, who’d had limited involvement with the health team other than for his ongoing back pain.
He’d had an assessment related to his being able to self-administer medication, and had “engaged well” in that process, denying any history of depression or thoughts of self-harm.
His parole reports had focused on his risk of reoffending, if released, rather than assessing his mental health and ability to reintegrate into society.
When released, he was considered a “medium risk” of violence and was not prioritised for psychological services in the community, and was placed on the “standard service” list instead.
Once released, he enrolled in a health practice, and when seen by both a nurse and doctor, had appeared mentally stable and well, apart from his ongoing back issues.
In June, concerns were raised by Probation after Kohiti expressed anxiety about “gang members finding him”. He had a session with a mental health services charity.
In mid-July he mentioned to Probations about wanting to go back to prison, and following that, was marked as “top priority” for psychological treatment, but hadn’t been allocated a psychologist at the time of his death.
Coroner Hesketh was satisfied that the death was self-inflicted, referring to a note that contained his intention to end his life.
Coroner Hesketh ruled Kohiti died sometime between July 25-28 last year.
Coroner recommends long-term prisoners be marked ‘urgent’
Coroner Hesketh noted there had been a number of suicides of former prisoners after their release from prison.
He reviewed a “brief selection” of six incidents between 2013-22 and noted that in all but one, the suicides happened within a “relatively short period following the deceased’s release from prison”.
The one exception was a man who took his own life nearly two years after being released but, like Kohiti, he was a life parolee and subject to strict release conditions.
Like Kohiti, the other deceased had “limited family support”.
Coroner Hesketh said there was much research that identified the risk to recently released inmates, and work was being done in New Zealand, with the Department of Corrections “acknowledging the importance of transitions when supporting people at risk of suicide and self-harm”.
He also referred to an American study about the particular challenges for those who are incarcerated while young, given Kohiti was only 19 when he went to prison.
The study noted that it was harder for them to adjust to technology advancements, changes to their interpersonal relationships, and the pressure of living under constant surveillance, as well as the shame and stigma of their violent past.
A long-term action (2023-2025) in a suicide prevention and postvention plan adopted by the Department of Corrections aims to target issues related to suicide risks in released prisoners.
However, Coroner Hesketh has said he supports “further areas for consideration” set out in a 2024 report done by the Office of the Inspectorate, which is an independent function of the Department of Corrections that is tasked with ensuring the safe, fair and humane treatment of offenders in prison and in the community, and carrying out investigations where necessary.
This report identified that Corrections should consider strengthening multi-agency collaboration for service provision for prisoners on release; consider the effectiveness of a previously-trialled “discharge nurse” role; and consider collaborating with external partners in data-gathering on suspected suicides.
Coroner Hesketh added a further recommendation that long-term prisoners “have their cases marked as ‘urgent’ to receive psychological services support in preparation for their release in the critical weeks and months both before and after their release”.
He said it was clear from the research that prisoners face many challenges when re-entering society.
“That is particularly so for those who have served longer-term sentences as they have become heavily institutionalised, becoming socially isolated, and lacking exposure to the changes in society.”
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.