A man was taken into police custody alive. Soon after, alone in a cell, his heart stopped beating. A Sunday investigation reveals police misused a spit hood and failed to follow their own policies, raising serious questions about his death.
On July 1 2018, Alo Ngata was pulled out from the back of a police van at the Auckland City Custody Unit.
His wrists were cuffed behind his back, his ankles tied together, and his entire face covered by a tight, opaque fabric.
CCTV footage showed his head slumped forward and his body limp. Only his foot appeared to be twitching.
About 20 minutes later, face down and alone in his holding cell, Alo’s heart stopped beating. He never regained consciousness.
Police completed two internal investigations and concluded “no person is criminally culpable for Mr Ngata's death".
For two years, his heartbroken family have wanted to tell his story. It’s a story that starts and ends in pain.
Alo's autopsy reveals that on the day of his death, he was likely suffering from excited delirium syndrome - a kind of psychosis resulting in extreme agitation and aggression. It can be triggered by drug use and mental health issues.
The sufferer experiences paranoia, panic, unexpected physical strength, and high body temperature.
Professor Jason Payne-James, a UK-based independent specialist in forensic medicine, said excited delirium syndrome is a serious medical emergency.
“The key element is you see somebody being violent, aggressive, very agitated, continuous movement, running around striking things, attacking people. But not in the sense that it’s intentional. It's all part of this syndrome.
“As a medic I would say that without doubt, anybody with excited delirium syndrome is vulnerable, they are at risk of sudden death."
Alo had no history of violent offending. Family and friends struggle to understand his actions on the day of his arrest.
The parents of his girlfriend, Romaine and Ralph, were there on the day of the incident.
“I could see there was a drug being used. I already knew my daughter was using methamphetamine. Both of their behaviours were quite erratic,” said Romaine.
They say on July 1, the day he was arrested, Alo was unusually volatile.
“He was up and down, smiling and the next minute ‘grr, grr’ and then smiling, and then talking humbly. His tone would come down and then he’d go straight into talking about protection, and drugs,” said Romaine.
After an argument inside the Auckland central flat where Alo was staying with his girlfriend, he ran outside enraged.
“He was slapping his head, then he saw this old man walking past and he just ran up and hit him,” said Ralph.
The attack was brutal. Alo stomped on the victim Mike Reilly’s head several times, leaving him in a life-threatening condition.
During the attack, Alo also turned on himself.
“He was jumping up in the air and he went headfirst into the concrete with his hands behind his back,” said Ralph.
“There was blood all over his face."
Police arrived at the scene at about 3.20pm and found Alo yelling, agitated, and completely unresponsive to their commands.
Two officers attempted to taser him but misfired three times. On the fourth try, Alo hit the ground face first.
In cellphone footage filmed by his girlfriend, four police officers are on top of Alo, and two more arrive to help restrain him.
Ralph said Alo was pepper sprayed at close range.
In footage captured by the taser’s inbuilt camera, Alo is heard shouting while under the weight of half a dozen officers.
“He looked at me and he asked me ‘help me, help me, help me brother. I can't breathe’,” said Ralph.
Roberts said police then pulled a spit hood over Alo’s face.
A spit hood is an approved police restraint tool designed to stop spitting.
The NZ Police Mechanical Restraint manual states that a spit hood must not be used on “anyone who is vomiting, having difficulty breathing or bleeding profusely from the mouth and nose area”.
Police policy also states that after the use of pepper spray (also known as Oleoresin Capsicum spray) officers must ensure the “person's face is not covered and they are not left lying face down with their hands constrained behind their back”.
“This may lead to positional asphyxia, where the position of the body interferes with breathing,” the policy reads.
But information released to Sunday under the Official Information Act reveals officers have failed to follow their own policies by hooding individuals after they have been pepper sprayed.
In 2018, ten people were pepper sprayed and then had the spit hood applied, including Alo.
Last year, the breach of police policy happened 13 times.
The first spit hood police attempted to put on Alo ripped. While the reasons are unclear, it may have been due to the large size of his head.
The instructions for the spit hood state: "If there is difficulty applying due to the large size of head, discontinue use.”
A second spit hood was applied to Alo, but incorrectly - pulled up over his mouth, nose and eyes - against the manufacturer's warnings and making it impossible for police to properly monitor his condition.
Alo’s arrest was intense. The unarmed 29-year-old was subject to the combined effects of pepper spray, taser, and intense physical restraint, but police say the use of force was justified and necessary.
The 76-year-old victim survived, but lives with the effects of the injuries. His family are now in a dispute with ACC to fund his necessary treatment.
“We remain grateful to the New Zealand Police who saved Mike’s life and are sad for Alo Ngata and his family's tragic loss,” his son told Sunday.
Speaking at a press conference shortly after Alo’s death in 2018, Superintendent Kathryn Malthus said if the officers hadn’t tasered Alo, they might be dead, calling it a "violent and volatile" incident.
"The deceased was acting so violently that it would not have been the correct option to go forth and to try to lay hands on him and restrain him in that way,” she said.
Witnesses largely agree, including Ralph and Romaine who said police had to act quickly and decisively.
But the pair believe the situation became dangerous once Alo was restrained at the scene, face down on the concrete, wrists and ankles tied up, spit hood on, with the weight of multiple officers pressing into his legs, back and head.
“He wasn’t fighting the police anymore, I think he just kind of gave up and just went along with what the police were doing to him,” said Ralph.
By the time he was put into the van, he was no longer a threat, said Ralph and Romaine.
“I tried to intervene with the police, let them know I work in mental health. Please I've got something to tell you, bring in the crisis team” said Romaine, a mental health and addictions support worker.
But she said no one listened to her.
“I knew he was gonna end up dead. It did not surprise me.”
Speaking to the media in 2018, Superintendent Malthus told reporters Alo continued to resist police while in custody.
“This was a man who was still resisting police interaction with him after he was restrained and put into the vehicle. When he was taken out of the vehicle, he was still resisting with police,” she said.
But CCTV footage showed Alo was barely moving when being transferred from the van to his cell at the Auckland Custody Unit.
“At no stage during this transfer does he appear to make any purposeful movements,” wrote the pathologist who conducted Alo’s autopsy, noting that Alo may have already been in “lowered level of consciousness”.
He added that when officers reached the cell and released Alo, “there is no response from [Alo] when he comes into contact with the floor”.
Six police officers spent about ten minutes in the cell with Alo. They held him firmly, moving him from side to side while removing taser prongs from this clothing.
CCTV footage showed that at no point did officers lift the spit hood to check his condition and he remained face down for the majority of this process.
The pathologist wrote that during this time, Alo made “very little movement”. At one stage his leg moved, but “it was not clear if this was purposeful” or if Alo was in fact suffering a “focal seizure”.
In response to Alo’s leg moving, the officers are seen applying pressure to his back, head and legs, with one officer bending his legs back as he lay face down on the floor.
“All this while he continues to wear the spit hood which was clearly covering his whole face, including his eyes”, the pathologist wrote.
“The presence of spit hood would have made monitoring of any vital signs, including whether or not he was unconscious, even from the time of removal from the van, impossible, given that the spit hood appeared to be covering his whole face.”
Spit hoods are a controversial tool worldwide.
The United Nations regards hooding as torture, saying the practice of fully covering the head of a person is cruel, inhuman and degrading treatment.
Professor James-Payne said police often justify the use of spit hoods by arguing they prevent illnesses contracted via spitting, but he said there is little evidence to show the hoods are actually effective in doing this.
“I don't feel they are necessary. There is minimal evidence to suggest that law enforcement personnel are at risk of communicable diseases in any event from, say, bites or spitting."
New Zealand Police data collected between 2011 and 2019 shows spit hoods were used 1227 times by officers.
The use of spit hoods has increased significantly year on year. Only 12 were used in 2011 compared to 257 in 2019.
Professor James-Payne said spit hoods have not been rigorously tested and there have been no studies to look at their use in a police setting.
“I think that if somebody's bleeding from the mouth, and if they vomited, if they got mucus coming out their nose, then there is potential for that airway to be compromised.”
In November last year, two Canadian constables were found guilty of criminal negligence causing death after putting a man in a spit hood and leaving him in a cell without monitoring him.
The man vomited inside the spit hood and suffocated to death. It was the same model spit hood that Alo wore.
After Alo’s restraints were removed, CCTV footage showed police exiting the cell, leaving Alo lying face down on the floor, the spit hood still on.
“It would have been extremely difficult to monitor his vital signs while he was lying prone on the floor,” the pathologist wrote.
In the Mechanical Restraints policy, staff are warned of the risk of asphyxia.
“The person must be kept under constant monitoring and never allowed to lie face down.”
The policy also makes clear there is an increased risk of asphyxia in those who are “highly stressed or agitated” especially if they are wearing a “spitting hood”.
Alo did not move. He remained face down in the cell, arms still behind his back despite the restraints having been removed.
CCTV footage showed officers peering through the cell window at Alo motionless on the floor, and at one stage, shining a torch through a slot in the door.
“In my opinion while this man was being observed by the officers from outside the cell he was essentially in an abnormal heart rhythm or cardiac arrest,” the pathologist wrote.
After a few minutes, an officer opened the cell and kicked at Alo’s feet. When there was no response, two officers entered, turned Alo on his back, took off the spit hood, and searched for a pulse.
Blood was visible in the CCTV footage where the hood’s fabric was covering Alo’s mouth and, according to the pathologist, this “fluid between the hood and face would have led to the formation of a relatively impermeable membrane and thus potentially restricted his breathing”.
Alo’s mother, Alofa, said it took officers more than five minutes after officers left the cell, to return and start CPR on her son.
“The delay in the restoration of his heart rhythm has meant that his brain has been starved of oxygen and has thus sustained irreversible damage,” the pathologist wrote.
Alo was taken to hospital. Surrounded by his family, his life support was turned off three days later.
According to the autopsy, Alo died from brain damage caused by a heart attack, due to combined effects of being restrained, methamphetamine, an enlarged heart and possible suffocation due to the spit hood.
“The possibility that the spit hood has contributed to his death by impeding his ability to breathe cannot be quantified, but also cannot be excluded. I accept the role of the spit hood is open for debate,” wrote the pathologist.
Last year, Alo’s family were allowed to view the footage of Alo’s arrest and detainment under police supervision. They were appalled at what they saw.
An internal police investigation was completed over a year after his death, and the organisation decided not to charge any officers.
“The police critical incident investigation examined criminal culpability.
“It has been determined after consideration of expert evidence and independent legal advice that legal causation for Mr Ngata’s death was not established and on that basis no person is criminally culpable for Mr Ngata's death,” said a police spokesperson.
The family repeatedly requested the release of CCTV and reports from the police.
Earlier this year, after nearly two years of waiting, they were given a copy of the footage and police reports by the Coroner with strict direction to neither share nor distribute them while the coronial process is underway.
No date has been set for the Coronial Hearing.
An Independent Police Conduct Authority Investigation is yet to be released.
Police turned down a request for an on-camera interview, and in a written statement said they don’t provide detailed commentary on matters that are still subject to judicial processes.
Police also said no officers have been subject to any internal employment processes, given the finding of the police investigation.
“Police is an organisation committed to on-going learning from any incident or event we attend," the statement said.
Alo Ngata died before meeting his first son, born five months after his death.