The Office of the Inspectorate has released a damning report into Corrections' handling of the the Waikeria Prison riot in 2021.
It lasted six days, from December 29, 2020, until January 3, 2021, involving up to 21 prisoners in the so-called 'Top Jail'.
"The riot was violent, destructive, and presented a real risk to life," said Chief Inspector Janis Adair in her report.
"It was not a peaceful protest; nor was it a proportionate response to prisoners' dissatisfaction with prison conditions. Nonetheless, this inquiry has found significant issues with the Department of Corrections Ara Poutama Aotearoa's preparedness for, and response to, this disorder event," she said.
Chief Inspector Adair made a total of 121 recommendations in her report to help address some of those "issues", which related to staff training, equipment, building security, roles and health and safety, among others.
Before the riot took place, the Ombudsman had found conditions at Waikeria Prison to "not be conducive to humane treatment of prisoners. The daily cell-to-yard regime is devoid of meaningful engagement."
Over the course of 2020, there were 113 incidents relating to the prisoners involved in the riot.
Plus, in the seven days leading up to the riot, 20 incidents were recorded in the Top Jail, including abuse, threats of violence or violence towards staff, prisoners fighting, and attempting to bribe a corrections officer.
'It felt normal'
The report said disorder was normalised in the Top Jail, according to some prisoners.
“My experience there was I guess normal if that makes sense, like even though the conditions were shit and rugged that’s what I thought jail was, and it felt normal," one prisoner told the inquiry.
When disorder broke out in the Top Jail's Yard 116 (high-security unit) it found there was a lack of early decisive intervention and several opportunities were missed to prevent the situation from escalating.
During the first few hours of the riot, Chief Inspector Adair noted there was "poor communication and ineffective command and control."
At 10am on December 29, 2020, a guard saw a prisoner giving another a haircut with a disposable razor - a banned item.
A corrections officer asked for it to be handed over, and a verbal altercation took place.
Twenty minutes later, staff told prisoners to exit the yard one by one. Some refused, with one saying "you're dreaming bro, get the f**k out of here".
Some prisoners even covered themselves in soap to make it harder for guards to get them out of the yard.
CCTV cameras were covered with wet toilet paper and some prisoners covered their faces with plastic wrap.
Shortly before 11am, the disposable razor was handed over, and the men were left in the yard.
That's when several calls were made from the yard's payphone, with prisoners smoking cannabis and in possession of a lighter, against prison rules.
Prisoners call Newshub from the yard
At midday, one call came to Newshub. Newshub then called Corrections at 1pm, warning them there was going to be another riot.
The prisoners covered the yard's cameras and started to light fires by about 1:50pm.
One prisoner called Newshub again at 2:20pm.
Corrections staff couldn't regain control of the yard because some staff thought the situation had been resolved when the razor was handed over, while others were reluctant to clear the yard as they didn't feel there were enough staff to respond safely.
Staff who saw prisoners smoking cannabis didn't take immediate action to confiscate the contraband, and no senior staff were advised about the cannabis or lighter.
Corrections staff failed to regain control of the situation because some felt there was a deescalation when the disposable razor was handed over.
Firefighters eventually arrived at the Top Jail at 2:30pm.
Then at 3:20pm, a group of prisoners broke through a mesh grille covering the yard, with nine of them climbing through and climbing up to the roof.
The nine men were members of seven different gangs.
Five minutes later, a Code Red (possible total lockdown of the prison) was called. Staff said the smoke coming from the fires was "toxic".
The remaining prisoners were taken out of Yard 116 by 5pm, but the prisoners on the roof went around using metal objects to ram open the cells of eight other inmates.
Two inmates who didn't want to leave their cell were told they'd be burned and thrown off the roof if they didn't.
Twelve more men got up to the roof, but by 9pm four had come down.
That left 17 prisoners on the roof, who stayed there for another five days.
Riots come to an end
The riots eventually came to an end on January 3, following negotiations involving Te Pāti Māori co-leader Rawiri Waititi, with the prisoners surrendering.
In her report, Chief Inspector Adair recommended that Corrections/Ara Poutama must provide progress reports to her office every six months.
It must also realise its Hōkai Rangi strategy, due to limited engagement in programmes including for tikanga Māori.
Chief Inspector Adair also said correct processes for the placement of prisoners needs to be followed and that staff need "sufficient training, experience, and support to fulfil their responsibilities."
She also added that Corrections' case management "fell well below acceptable standards".
Clean and appropriately-sized clothing and bedding must be provided to all prisoners across Aotearoa, she said, while urging Corrections to work better with emergency services.