Flawed systems and poor resourcing preceded the death of a Whangārei man who was allegedly beaten to death by his cellmate, according to a report obtained by the Herald.

This included the Mt Eden forensic prison team (FPT) having “no information” about the victim’s cellmate, or any input into the decision to put the two mentally unwell men together.

That team includes specialist psychiatrists, clinical psychologists and psychiatric nurses.

The draft review by Health New Zealand (HNZ) also found that on-call forensic psychiatrists visiting Mt Eden prison were unable to access important health records – because they were shut out of the system used by Corrections.

The tragedy happened at a time when mental health personnel at the prison were overstretched and understaffed, the report said.

Rob Fitzpatrick died at Auckland's Mt Eden Corrections Facility. Photo / Annaleise Shortland.

The review investigated the circumstances leading up to the death of Rob Fitzpatrick, who was placed in a shared cell with a man alleged to have killed him on June 27 last year.

In the months before Fitzpatrick’s death, he was seen by mental health teams in both hospital and prison settings.

Mt Eden Prison, where Fitzpatrick died, has a dedicated team of forensic mental health specialists, whose job it is to oversee the care of prisoners in distress.

But the report reveals they were not involved in crucial accommodation decisions. “There was no systematic understanding of arrangements for shared cells, and of the potential compatibility issues for cellmates,” it says.

The report said that despite weekly meetings between health and Corrections staff about new arrivals, neither Fitzpatrick nor his cellmate was discussed.

‘They should have all information’

Dr Hiran Thabrew told the Herald it is dangerous when specialist health staff cannot access the information they need. Photo / Cole Eastham-Farrelly

Chair of the Royal Australian and New Zealand College of Psychiatrists, Dr Hiran Thabrew, told the Herald an arrangement where specialists don’t have information about those sharing cells, nor input into bunking decisions, is dangerous.

“Prison health teams should have access to all appropriate information in a timely manner,” he said.

The review said double-bunking decisions are largely the responsibility of Corrections and there is no formal structure for the insights of other experts to be considered.

It recommended that prisoners’ “risk history” and details of their alleged offending be shared with the FPT so they can properly understand and advise on cell-sharing arrangements.

Currently, Corrections carries out risk assessments when deciding who is suitable to be put in a shared cell – a system now under review.

‘Staff shortages’

According to the report, the problems were compounded by staff shortages at Mt Eden prison, including nursing vacancies at the time of Fitzpatrick’s death.

Specialist mental health staff at Whangārei Hospital, where Fitzpatrick had previously been a patient, were under similar strain.

The psychiatrist involved in Fitzpatrick’s most recent admission there told the review team he was sometimes “the only senior medical officer on the ward”.

“Forensic mental health teams reported chronic understaffing and high workloads, with minimal clinical supervision or governance oversight,” the report said.

At Mt Eden Prison, the shortage of forensic mental health staff also coincided with growth in the inmate population.

Thabrew told the Herald the problems extend across the country. One in five publicly funded psychiatry positions are vacant and forensic services have been hardest hit, he said.

“Those shortages, particularly in forensics, are having a significant effect on care – but also for psychiatrists to be able to train future generations of forensic psychiatrists. People are quite stretched – there’s high turnover and burnout,” he said.

Thabrew said the reduced capacity of the workforce means people are spending longer in prison waiting to get into forensic mental health units like the Mason Clinic – an experience that can compound mental distress.

‘Fragmented systems’

A draft review points to safety concerns because of an inability to share medical records.

The review also found that health officials and Corrections use multiple incompatible IT systems to hold clinical records – impacting safety.

“Clinicians and custodial staff cannot easily access or share timely data, contributing to critical gaps in understanding a person’s care trajectory ... ”

Thabrew said information sharing across health had been a longstanding problem.

“Even between DHBs in the health system, we know there are issues when people are transferred from one area to another.”

Even fulltime forensic staff at Mt Eden had “limited information” about inmates, leaving them in the dark about the seriousness of offending, the review noted.

Family ‘excluded and helpless’

The family of Rob Fitzpatrick (inset) believe failures by multiple government agencies culminated in his death. The 46-year-old who had mental health issues was allegedly beaten to death by his cellmate while double bunked at Mt Eden prison.

Fitzpatrick’s family was critical about the poor communication from various agencies, according to the review.

They described “rushed or poorly planned” discharges from hospital, leaving them scrambling to find Fitzpatrick safe accommodation, and frustration with not being able to get help from mental health crisis teams when Fitzpatrick was unwell.

In other instances, he was arrested without them being informed, the report said.

On one occasion, the family was blocked from visiting Fitzpatrick in prison because he struggled to fill out the documentation.

The draft report recommended that all mental health and addiction services work to improve contact with families.

The Herald has sought clarity about when HNZ’s review will be finalised, but has yet to receive a response.

Mental Health and Addiction national director Phil Grady previously said any recommendations will be implemented quickly.

“We are always looking to improve how we deliver the best possible patient-centred care.”

Michael Morrah is a senior investigative reporter/team leader at the Herald. He won News Journalist of the Year at the 2025 Voyager Media Awards and has twice been named reporter of the year at the NZ Television Awards. He has been a broadcast journalist for 20 years and joined the Herald’s video team in July 2024.