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Police and the Wellington coroner are calling for detox centres to be set up so drunken prisoners are not automatically put into cells.
Coroner Garry Evans has added his voice to police concerns after his inquest into the deaths of two heavily intoxicated men taken into police custody within days of each other.
Francis James Hurd, 68, was found on a footpath in Upper Hutt around 10pm on November 5, 2005.
He had what police said appeared to be a very small wound to the back of his head, having fallen from a small wall as he picked grapefruit from an overhanging tree.
Police recognised Mr Hurd and, knowing he was a heavy drinker and lived alone, they decided to take him to the station to "detox".
A watchhouse constable said he checked on Mr Hurd throughout the night and at 5am noticed he was covered in faeces. Police practice was to wait for the person to wake up before allowing him to shower.
By 11am Mr Hurd had not woken up so a doctor was called in. Mr Hurd was taken to Hutt Hospital, where scans showed his head injuries were worse than they had appeared.
He was transferred to Wellington Hospital, where he died three days later.
A post-mortem examination showed he had fractures to his skull and swelling underneath the wound.
Hutt Hospital's emergency department head, Dr Richard Makower, told the inquest head injuries were difficult for health professionals to assess, let alone police officers.
Mr Evans said the way the police managed and assessed Mr Hurd was unacceptable. "In hindsight, the officers who were called to find him lying unconscious, with a head injury, should have called an ambulance."
Had there been better direction for police - through policy or instruction - Mr Hurd would have received immediate treatment and possibly survived.
Mr Evans said Mr Hurd should not have been taken into custody and ended up in a cell only because there was nowhere else (apart from hospital) that he could go.
"There was no one who could look after him at home and the temporary shelters and detoxification centres that should have been available have never been established."
Mr Evans found Mr Hurd died of the effects of the head injury received when he fell from the wall while he was drunk.
A complaint to the Independent Police Conduct Authority is being investigated.
The morning after Mr Hurd's death, an intoxicated Henry Reubin Grace, 43, was arrested in Wellington's Cuba Mall after police received complaints of his behaviour.
He was epileptic but often didn't take anti-convulsant medicine.
Mr Grace told police he had taken his medicine "a while ago" and was not marked as "at risk".
At 2.45pm an officer looked into his cell and saw Mr Grace collapsed on the floor with his head on the bed.
An autopsy showed he had died of a "seizure disorder" possibly brought on through alcohol withdrawal.
The police duty sergeant told Mr Evans he had not been trained in "appropriate medical questioning" and did not understand the seriousness of Mr Grace's condition.
Mr Evans said Mr Grace "should have had the opportunity of examination by the police duty doctor" which would have offered the "possibility of a better outcome".
He said there was a need for consistent guidelines with clear directions on how to deal with people taken into custody with certain conditions.
Mr Evans found Mr Grace died of a seizure disorder at Wellington Central police station.
The Independent Police Conduct Authority is investigating.
After receiving the court's findings in March, Inspector Tom Ireland wrote a submission, highlighting issues with the way intoxicated people are processed.
He said the Alcohol and Drug Addiction Act 1966 had anticipated the establishment of "detoxification centres".
This never happened and "consequently, police cells by default are used for this purpose".
Mr Ireland said police cells held an estimated 125,000 to 140,000 prisoners a year. On average 40 per cent of those prisoners were drunk.
On a Friday and Saturday night this figure climbed to 70 to 80 per cent.
Mr Ireland said police believed "sobering-up centres" were needed to ensure people received proper medical assessment, supervision, counselling and education.
- NZPA
