http://www.stuff.co.nz/the-press/news/3276344/Death-report-a-whitewash
By JOSH REICH - The Nelson Mail

The family of a Golden Bay man who died in Christchurch Men's Prison say a coroner's report into his death is a whitewash and they would like an apology for what happened.

Stephen Cleary, 49, died on June 11, 2007, from a pulmonary embolism arising from deep-vein thrombosis in his right calf.

He was beginning a one-year sentence for growing cannabis. After being sentenced on June 1, 2007, Mr Cleary spent five days in unusually restrictive conditions in the Nelson police cells and was transferred to Christchurch in a prison van on June 6, 2007.

In a report on the inquest into Mr Cleary's death, chief coroner Neil MacLean said the death was "probably avoidable" if someone had taken a complete overview of his care and custody.

However, he said it was unrealistic to make any meaningful criticism of the actions of any person involved in Mr Cleary's case. He did not make any specific recommendations in relation to Mr Cleary's death.

A spokeswoman for the family said today the report was a "whitewash" and did not provide them the answers they were looking for.

"The coroner's report ... it was really watered down ... really basic, and didn't give any of the facts that the family were concerned about."

It failed to explain why the nurse who dealt with Mr Cleary in prison looked at his symptoms in isolation. "This one person over several occasions let it slip and just ignored the signs.

"It's all in hindsight, but in a way it highlights that when things aren't good, it doesn't pay to get unwell in prison.

"You wouldn't get the same treatment as the general public, and that's what he had a right to." She said the family would like an apology.

The report said Mr Cleary had complained of pain in his lower right leg at the Nelson police station, but he attributed it to a torn muscle after doing some squats in the cells. "That belief probably coloured the observations of others, including himself," the chief coroner said.

He said no one, including the family's GP, was aware of Mr Cleary's possible predisposition to deep-vein thrombosis.

When Mr Cleary arrived at Christchurch Men's Prison, he told nursing staff he had pulled a muscle, and on June 9, 2007, he was unable to bear weight on his leg.

Two days later, he called on the cell alarm for help, complaining of being short of breath and feeling dizzy with pain in the lower left leg.

The nurse diagnosed Mr Cleary as hyperventilating, and no further action was taken.

Later that day he collapsed outside his cell and was declared dead at 3pm.