A coroner is calling for a national legal help phone line for prisoners in police custody after a lawyer could not be found for a man who later hanged himself in his cell.
"The bottom line is that people in custody must be able to obtain legal advice," coroner Wallace Bain said in a report on an inquest he held into the death in May last year of Rotorua chef Anthony Patrick McGuire, 33.
Dr Bain is also recommending that police adopt a zero tolerance policy towards lapses in their procedures after a series of "frankly unbelievable" failings led to Mr McGuire's death in a Rotorua police cell.
These included a lack of risk assessments after his first-time arrest over an alleged domestic incident and then placing him in the cell without relieving him of his shoelaces, drawstrings on his sweatshirt and track pants, a pounamu necklace, a bracelet, cigarettes and a lighter.
Mr McGuire's name was put on the wrong cell, he was not fed, finger-printed or photographed and was not frequently monitored - despite a whiteboard instruction in the police watchhouse for that to happen.