The police organisation and individual officers failed in their legal duty of care for a man who died from a drug overdose while in police custody in November 2017, the Independent Police Conduct Authority (IPCA) has found.
The man was held at the Hawke's Bay Area Custody Unit on November 12, 2017, where he resisted police officers' attempts to search him, the police watchdog said.
His health and wellbeing were not properly assessed at the time due to his agitated state, leading police to miss warnings on his life - particularly that he had suffered a brain injury in the past and that he did not take his prescribed medication to prevent seizures.
During the night, the man took a large dose of methamphetamine and, in the early hours of November 13, he suffered prolonged and increasingly violent seizures, after which he died.
An officer placed a breakfast tray in the man's cell at 5.42am on November 13, but his death was not discovered until around 10am that morning when an officer attempted to wake the man to take him to court.
The IPCA found that officers in the custody unit had repeatedly failed to perform their duty of care for the man and, while their omissions did not cause the man's death, they were serious and inexcusable.
"Police policy exists precisely to manage risk and avert the sort of outcome that occurred in this case," IPCA chair Judge Colin Doherty said. "The omissions of officers to comply with that policy were likely to cause injury or suffering to a vulnerable adult such as this man.
"Poor leadership, supervision and support of custody staff contributed to a culture in the custody unit that tolerated a repeated and serious disregard of police policy and good practice."
The Authority found that there was insufficient evidence to support a criminal prosecution of any individual officer, and the police could not be held criminally liable for the potential Crimes Act offences identified in the report. However, the IPCA noted that the police could be held criminally liable for the actions of staff who fail to fulfill their obligations under the Health and Safety at Work Act 2015.
The IPCA was unable to determine how the man accessed methamphetamine while in custody. Police have since carried out significant changes in the Hawke's Bay Area Custody Unit.
In a statement, police acknowledged the IPCA's findings, adding that the staff involved "acknowledge they failed to adhere to the procedures".
"This was a tragic incident and my deepest sympathies remain with the man's whānau," Eastern District Commander Superintendent Tania Kura said in a statement.
"I am very disappointed that on this occasion we did not follow the standards and policies established to keep detainees safe. The staff involved acknowledge they failed to adhere to the procedures."
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