A coroner overseeing the inquest into the death of a Department of Corrections officer has vowed to do as much as possible to ensure such a tragedy never occurs again.
Jason Palmer died in May last year after being punched by inmate Lapu Kepu who was being removed from a cell at Spring Hill Prison in Waikato.
He was later sentenced to more than six years' jail for manslaughter.
Coroner Gordon Matenga wrapped up the two-and-a-half day inquest in Auckland on Wednesday, telling Mr Palmer's widow the incident clearly came as a surprise to all the guards involved and was a tragedy.
Mr Matenga's comments followed a morning filled with conflicting evidence about whether the inmate had made threats against Mr Palmer just hours before he died.
One of Mr Palmer's colleagues gave evidence about the threats, but the Department of Labour said there is not enough evidence to confirm that, as the man gave different accounts to different authorities.
Gavin Dalziel was prison manager at the time of Jason Palmer's death. He told the inquest on Wednesday Mr Palmer would still be alive today if another officer had told managers about threats made by Kepu.
Earlier this week, a prison officer told the inquest that Kepu had threatened to hit him before the fatal attack on Mr Palmer.
The officer said that Mr Palmer also knew about the threats, but no-one passed the information on.
The Department of Labour told the hearing on Wednesday it did not have enough evidence to charge the prison officer for failing to alert authorities about Kepu's threats towards Mr Palmer.
Health and safety inspector Paul West said the guard who gave evidence had told different stories to police, the Corrections Department, the Labour Department and his colleagues - and none of them corroborate.
Mr West said that meant it was too hard to determine whether the threats were actually made, and then charge him under the Health and Safety Act for not reporting them to management.
The inquest concluded on Wednesday, but the coroner's findings will not be released until next year.
