Alo Ngata was arrested after a lengthy struggle with police in 2018. Photo / NZME
A custody officer said she knew something was wrong when she saw Alo Ngata's hands turning blue in the police cell where he was lying face-down in a spit hood.
Michelle Sullivan said she also thought she heard him say "I can't breathe" at one point when he was being searched.
She later asked if anyone else had heard it.
"And no one said they did, which put doubt in my mind," she said at the coronial inquest into Ngata's 2018 death in custody in Auckland this morning.
The inquest opened on Monday with police officers who arrested Ngata giving evidence, including the officer who fitted the spit hood, the most junior and last to arrive at the scene.
Ngata, 29, was arrested on July 1, 2018, after allegedly assaulting an elderly man at random in central Auckland, followed by a lengthy and violent struggle where he had to be tasered and physically subdued by several officers.
He was declared brain-dead and died in hospital three days after his arrest.
Sullivan was one of the first people to raise alarm bells at the Auckland Custody Unit where she was told Ngata was "coming in hot", she said, using police jargon for non-compliant detainees.
Sullivan said she expected Ngata to be thrashing and agitated on arrival at the custody unit, but he wasn't, she told the inquest.
She was observing him lying in the cell on a screen when it looked like his hands were turning blue. "That's when I got seriously concerned."
She immediately told the off-duty sergeant sitting next to her, and also heard someone else saying Ngata was not breathing anymore.
Her job included manning the door to the cells, so she asked the supervising officer if she should open the door but was told no a couple of times. "Which was frustrating because in my head there was urgency and they needed to get in there," she said.
Representing the Police Association, Susan Hughes, asked if this was because the officers were making a re-entry plan, preparing for cases where a detainee could spring up and attack officers on entry.
"I think so, but I wasn't part of the decision-making," Sullivan said.
She saw officers putting on gloves before she was eventually told to open the door.
Several officers went in, turned Ngata over, checking and rechecking his pulse, and got a defibrillator, she recounted.
She recalled feeling frustrated they hadn't started CPR, but once she suggested it "the penny dropped" and CPR began, she told the inquest.
She rushed for a pair of scissors to hand to one of the officers to cut open Ngata's shirt, and called the ambulance, which arrived 11 minutes later.
The off-duty sergeant sitting next to Sullivan, John Reweti, also alerted the supervisor on duty when he noticed something wasn't right.
"We've had a lot of training about the consequences of leaving people lying face down," Reweti told the inquest.
"After spending a long time in the cells you get a gut feel when things are not going well," he said.
"To me it felt like he still had handcuffs on," he said, even after officers had uncuffed him and removed the cable ties on his legs.
In a report about Ngata's mental health history, his GP Dr Richard Hulme said he was diagnosed with several mental health illnesses including bipolar disorder, hypomania, and substance use disorder.
He was referred to Middlemore Hospital and discharged in 2016 with two weeks of medication, which he did not continue after his script ran out, the inquest heard.
In the two years before his arrest, Ngata presented to his GP three times for gout and flu, but there was no evidence in these consultations that his mental health had deteriorated, so his medications were not re-prescribed.
The inquest continues this week.
The 19-year-old disappeared without her wallet or mobile phone.