That night eight other people were also detained.
About 7.20am on November 23, an officer went to speak to Martin in her cell and she was found dead.
“The circumstances of her death are before the Coroner for determination, but no evidence of a crime was detected,” the authority said.
The authority found that initially, the care of Martin in police custody was appropriate and in line with police obligations considering the information available.
“However, in our view receiving officers should have applied a wider consideration of Ms Martin’s circumstances instead of relying on a computer-based assessment and observation plan,” the authority said.
“Ms Martin had just been convicted of murder and was in poor health. If these considerations had been factored into the police assessment it is likely she would have been checked more frequently.
“Later, two officers acted unprofessionally, which presented a danger to all the detainees, by failing to complete physical checks as outlined in police policy; and by submitting a false record of physical checks which were not completed.
“One officer also displayed poor judgement when he left his duties during his shift.”
Police advised the authority that several improvements had been made at Gisborne since the incident.
“We also made two recommendations for improvements.”
The authority said it completed its investigation in May 2024, but was obliged to wait for the police employment process before publishing its report.
Police respond
Eastern District Commander Superintendent Jeanette Park said police conducted a review of the events around Martin’s death and came to a similar conclusion as the IPCA.
“Police accepts the actions of the officers were not in line with the standard of care we expect for those who come into police custody.
“Police have reinforced with staff in Gisborne and across the country that detainees must be checked correctly, not just via CCTV. We have made several improvements at the Gisborne Police Custody Unit and addressed staffing shortages.”
Park said police carried out an employment investigation into the officers working during this shift and provided them with additional training.
“We have reviewed our process to ensure that a recent conviction for a serious offence influences the monitoring schedule required for certain detainees.
“Custody units can be a complex and challenging environment to work in. Police remain committed to continuous improvement ensuring a high standard of care for the more than 120,000 detainees who come into our custody units across New Zealand each year.
“Police has implemented significant changes over the last few years, including the creation of a National Custody Team which provides oversight of the policy, practice, and training for all police staff,” Park said.