‘We could have done significantly better’: Corrections apologises four years after man died inside prison

Wednesday, 24 June 2026

Caleb Moefa’auo, 26, suffered a fatal cardiac arrest in April 2022 while being restrained face-down by guards inside Mt Eden prison.

The Office of the Inspectorate found the use of pepper spray during a dispute over a towel was “disproportionate” and his pleas that he could not breathe were ignored.

Coroner Heather McKenzie issued four major recommendations, including mandatory, specialist mental health training for all staff working in Intervention and Support Units.

Caleb Mark Moefa’auo was 26 years old when he died in his cell inside Mt Eden Corrections Facility. He had refused to hand back an extra towel, was pepper sprayed by an officer and restrained. Twenty minutes later he was dead. A coroner has now called for specialist in-depth mental health training for officers working in the Intervention and Support Unit (ISU). His family sat down with Catrin Owen as the findings were released.

For four years, Caleb Moefa’auo’s family has wanted an apology.

And now, as the findings of a coronial inquest into his death in custody are released, they finally have one.

“We acknowledge we should have done significantly better in the lead up to Caleb’s death, and for this we are truly sorry,” Emma Gardner, Corrections’ chief mental health and addictions officer said in a statement to Stuff.

Moefa’auo died on April 5, 2022, inside a Mt Eden prison cell after he was pepper sprayed and restrained for refusing to hand back a towel after showering.

In the aftermath, the Office of Inspectorate, an independent prison watchdog, identified various failings in his care.

Most significantly, it found a Corrections officer’s use of pepper spray was “disproportionate” and Moefa’auo’s comments that he could not breathe were not “sufficiently responded to”.

In an 88-page finding made public on Wednesday, Coroner Heather McKenzie said Moefa’auo died after suffering a cardiac arrest while being restrained face-down. An enlarged heart was identified as a contributing factor.

McKenzie said the care provided by the Forensic Prison Team (FPT) in the lead up to his death was not the standard of care “generally provided” and his mental health was not “sufficiently actively managed”.

She made several recommendations to improve the management of inmates with mental health needs, and prevent another such death in the future.

Corrections’ apology came after Stuff asked questions about what changes had been made since Moefa’auo’s death. The family haven’t received a direct apology from Corrections.

Accountability and change in the prison and mental health systems is paramount for the family - and the fight for that continues.

“It is wholeheartedly important,” Moefa’auo’s mother, Justine Lauese, told Stuff.

“It’s just not over. It is scary thinking that this could still happen to someone else and their family.”

Although Lauese is “grateful and respects” the findings and recommendations, the family want to know how the changes will be implemented, monitored and measured.

Identifying the mental health needs of those inside prison is “very important” and having people with “specialised training is essential”, Lauese said.

“It would have changed everything had they all stopped and thought about it.”

Caleb Moefa’auo, mental health and prison

Moefa’auo’s mental health journey started at a young age. At 19, he was diagnosed with schizoaffective disorder - a mental health condition where people experience a combination of schizophrenia and mood disorder symptoms.

For Moefa’auo’s mother, his death has left a “big emptiness”.

“He was loving, very cheeky, he liked to make people laugh, loved his family and he was very empathetic.”

In December 2021, Moefa’auo had been staying at Tiaho Mai, a residential unit supporting people with mental health issues. That was until December 22 after he allegedly assaulted a patient and appeared in court.

Despite a letter to the judge suggesting Moefa’auo be placed in a secure mental health facility - the Mason Clinic - he was remanded in prison.

The Mason Clinic wasn't aware of that letter and there was no formal assessment of Moefa’auo or his needs, Coroner McKenzie’s findings said.

While inside prison, Moefa’auo repeatedly declined to take some of his medication.

“Mr Moefa’auo raised multiple concerns with the health team about anxiety, depression, agitation, low mood, nightmares, sleep disturbance and migraines. Clinical assessments were not adequately made of these concerns,” the coroner said.

Lauese repeatedly tried to get her son released to a specialised mental health facility.

She remembers her final conversation with him days before he died. He’d just been released from isolation after contracting Covid-19.

“He wasn’t making sense to me, and I knew that he was very, very unwell.”

Despite this, Moefa’auo was excited for an upcoming court date and hopeful he’d be getting out.

A move to the ISU

On April 4, Moefa’auo was transferred back to the prison’s ISU, a unit set up for prisoners with high mental health needs, following a self-harm incident.

Most of the ISU staff had not met Moefa’auo before and weren’t aware of his mental health background.

On the morning of April 5, Moefa’auo was let out of his cell, wearing only a gown to have a shower.

He was handed two towels by officers.

While he waited for the cell to be cleaned, he walked over to a trolley of clean towels and picked up two, drying his hair with one.

Both his mum and his aunt, Lia’inaiala Burns, said that had the officers known Moefa’auo’s history, they would have picked up on triggers he was displaying at the time.

Prison protocol was that those inside the ISU can’t take towels or other items into their cells for safety reasons and are allowed only one towel at a time. (Since Moefa'auo's death, there are now visible signs and prisoners are made more aware of the policy.)

What happened next was fast moving and dynamic.

A Corrections officer (who has permanent name suppression) told Moefa’auo to hand back the towels. He refused and began walking back passively.

The officer, on his second day in an acting senior role, yelled repeatedly for Moefa’auo to return the towels and issued an order warning that if he didn’t comply he would be pepper sprayed.

Moefa’auo, appearing confused but not acting aggressively, was pepper sprayed about 45 seconds after the initial approach.

Police charged that officer for assaulting Moefa’auo with the pepper spray and he faced a jury trial in early 2024. He was acquitted.

The jury didn’t know Moefa’auo had died 20 minutes after being pepper sprayed.

Back to the morning of April 5.

The situation escalated as soon as the pepper spray was deployed.

Officers flooded the area. Moefa’auo was brought to the ground in an “unorganised manner” and handcuffed.

Despite Corrections policy, Moefa’auo wasn’t told about the effects of pepper spray. He repeatedly said he could not breathe before decontamination processes were attempted.

Moefa’auo was then returned to his cell.

“Consistent with their approach throughout the incident, the officers treated Mr Moefaauo as if he was actively resisting, without considering a less coercive approach was available,” the Office of Inspectorate found.

As he was lying in the prone position, his head was not supported and he vomited.

There was a delay of 45 seconds after an officer tried to remove handcuffs before CPR began.

Moefa’auo died in his cell.

His family had to watch those moments as the footage was played during the inquest.

“I try not to remember my son that way. It was a very distressing time to think that he went through that without us around him, he must have been thinking of us and just been so frightened,” Lauese said.

Recommendations

The coroner made four recommendations including specialist in-depth training for ISU staff, and daily and handover briefings, including an overview of each prisoner in the ISU.

“In Caleb’s case, on the evidence before me, if officers had known of his mental health challenges they might have taken a different approach to how they interacted with him during the incident,” Coroner McKenzie said.

Her final recommendation was for Corrections to review its communication modes and document management system, so officers in the ISU are provided with real-time information on prisoners.

‘Committed to learning from this tragedy’

Corrections’ chief mental health and addictions officer, Emma Gardner, said in a statement to Stuff, the department accepted all the findings and recommendations.

“I would like to again express our deepest sympathy to the family and loved ones of Caleb Moefa’auo,” Gardner said.

The department is “committed to learning from this tragedy”, and changes had already been made, she said.

All new custodial staff are now provided with mental health training and those in the ISU, and other relevant units, have tailored training.

“I want to again express my deepest apologies and condolences to all those who loved Caleb, and we encourage his family to contact us at any stage should they wish to meet us.”

Moefa’auo’s family wanted to make it clear they had never received a direct apology from Corrections.

“A genuine apology requires a direct expression of remorse and accountability to those most affected,” they said.

“Caleb's family maintains that real accountability requires more than public commentary. It requires direct engagement with those harmed, transparency in action, and a genuine acceptance of responsibility for what has occurred.”

Sam Wimsett KC and Harriet Krebs acted on behalf of Moefa’auo’s family at the inquest.

“I met Caleb’s family four years ago and it’s been a really long process to get here,” Wimsett said.

“They’re a beautiful family and they’ve been really patient and participated respectfully throughout.”