Prison ‘an unsuitable place’ for Alexander Nicholls-Braddock, who died by suicide – coroner

Source: Radio New Zealand

Corrections failed to properly monitor a man with ADHD and addiction problems who died by suicide in Christchurch Men’s Prison, a coroner has ruled.

Alexander Nicholls-Braddock, who was 29, was found dead in his cell on 19 March 2021, just over five weeks after he arrived.

It was his first time in prison, and he was sent there after being sentenced on his sixth charge of driving with excess breath alcohol.

Coroner Alexandra Cunninghame’s report into his death was released to RNZ. She ruled he died by suicide, but the way in which he died cannot be reported.

The report noted Nicholls-Braddock had a long history of addiction and mental health problems, and prison was an unsuitable place for him. The Coroner also found failings by the Department of Corrections.

Coroner Cunninghame said when Nicholls-Braddock was seven he was diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).

His mother gave evidence that he had talked about wanting to kill himself from when he was a child, and since his teens he had struggled with alcohol and substance use, she said.

Nicholls-Braddock was charged with driving with excess breath alcohol for the first time in 2011.

The sixth time was in 2020, after he crashed his vehicle on his way to whitebait at the beach. He was hurt in the accident, as was a dog which belonged to a member of the public.

“Alex was a person who enjoyed the outdoors, and he had made Haast his home. He had a partner and a supportive family, and was well-liked. Sadly, Alex had a long history of addiction and poor mental health, which affected his functioning and brought him before the Courts,” the Coroner said.

After the 2020 charge, in relation to the possibility of Nicholls-Braddock being sentenced to prison, his GP in a referral letter to an alcohol and drug service questioned if jail was the right place for him given how “fragile he is psychiatrically”, the report said.

Nicholls-Braddock was sentenced to 11 months imprisonment with leave to apply for home detention if a bed became available at mental health and addiction service Odyssey House.

He faced difficulties in prison, and died after being in there just over five weeks.

Consultant forensic psychiatrist Dr Erik Monasterio, who gave evidence at the inquest into Nicholls-Braddock’s death, outlined risk factors present in the lead up to the death.

They were alcohol and drug addiction and coping in the early stages of enforced remission, persisting anxiety and distress, thoughts of suicide, fears for his safety, an unexpected fine added to his sentence and the expectation of detention in his cell following internal prison charges.

“The combination of these factors occurring in the context of Alex’s vulnerable personality while isolated from his partner and family in custody “likely overwhelmed his limited coping skills and contributed to his death”, the Coroner said.

Dr Monasterio noted that a number of these risk factors had not been disclosed by Nicholls-Braddock to Corrections staff, and that since he seemed happy with the plan for him to be placed in the drug treatment programme while the Odyssey House referral was explored, “his risk for suicide was not considered to be elevated in the lead up and at the time of his death”.

Coroner Cunninghame found Nicholls-Braddock was bullied by other prisoners, and that Corrections did not adequately recognise or manage the risk which other prisoners posed to him.

“This resulted in his possessions being taken, his involvement in misconduct charges, and, on his account to Ms Pearce [Nicholls-Braddock’s partner], assaults. Alex’s phone conversations with Ms Pearce make it clear that these incidents were distressing to him, and that he believed that nothing could be done to assist him,” she said.

“Dr Monasterio recognised the bullying as impacting on Alex’s ability to cope in prison and increasing his suicide risk.”

The report said Nicholls-Braddock’s medical history and GP records, which referred to his mental health history and self-harm, were not requested when he was received into prison.

“Dr Monasterio considered the absence of these records “unfortunate” because it prevented prison staff from knowing the full picture about his suicide and self-harm risk. This is particularly important in the case of a prisoner such as Alex, who denied suicidal or self-harm thoughts or behaviour when he was assessed at the prison,” the Coroner said.

Dr Monasterio described the use of the ISU [Intervention and Support Unit] for the management of drug and alcohol withdrawal and for the detention and supervision of inmates with symptoms of mental illness as “inappropriate”. The report described how Nicholls-Braddock struggled in the ISU when he first arrived at prison.

Coroner Cunninghame made five recommendations to the Department of Corrections.

These included that concerns about bullying in prisons should be pro-actively managed and custodial staff should be trained to consistently record and manage these concerns, the process for obtaining prisoner’s health records should be reviewed to ensure that it is appropriate and consistently followed, and processes for contact and engagement with family/whānau, especially for first-time prisoners, including opportunities for direct contact with unit staff and case managers, should be improved.

“The strong feeling that ran through the evidence was that Alex should not have been in prison. Alex’s family and Ms Pearce were very concerned about how he would cope, as was his GP, and sadly these concerns came to pass,” Coroner Cunninghame said.

“Those of us who were in Court for the inquest heard Alex’s voice on the recordings of his phone calls. He was in distress in his last days, but I also heard his love for his family and his ability to find humour even in dark times. It is a tragedy that he was overcome by his ADHD and addiction, and that he ended up in prison, which everyone recognised was an unsuitable place for him. May he rest in peace.”

Christchurch Men’s Prison general manager Jo Harrex said while the causes of suicide were multifaceted and complex, Corrections was committed to doing everything it could to prevent deaths in custody.

“We would like to express our sincere condolences to the loved ones of Mr Nicholls-Braddock and acknowledge the ongoing pain they experience as a result of his death,” she said.

“Corrections accepts all of the coroners’ findings and recommendations. Since the man’s passing, Corrections has made multiple changes to help support prisoners with their mental health and wellbeing.”

Upon reception into prison, all people were screened for suicide or self-harm risk in the Receiving Office by a corrections officer and again during the reception health screen assessment, Harrex said.

Other changes included implementing additional training packages at Christchurch Men’s Prison for custodial and case management staff and holding regular multi‑disciplinary team meetings involving staff such as case management and custodial staff to support those who had been identified as vulnerable, high‑risk, complex, or who required additional oversight for other reasons.

Harrex said Corrections expected to release its updated Suicide Prevention and Postvention Action Plan soon.

“Relevant medical and health information is managed in accordance with health privacy requirements, which limits routine sharing amongst health and non-health staff. Where such information is identified and considered helpful, custodial and case management staff work closely with their health services colleagues. However, some court ordered documentation remains restricted, and cannot be shared without the consent of the court and/or the prisoner. With prisoner consent, relevant non-restricted health information may be loaded on our internal systems,” she said.

“Acknowledging there is a need to improve access to support, we are currently collaborating with Health NZ, the Ministry of Health, the Ministry of Justice and other partners to ensure people in prison who have severe and acute mental health needs, or an intellectual disability, are receiving timely support.”

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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand

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