According to the decision released today, the man was arrested in West Auckland in October last year for a breach of bail. Officers had spotted him in the passenger seat of a car but he ran off before he was arrested shortly afterwards.
Police later found two bags in the vehicle, which they took to the Waitematā District custody unit where the man was locked up awaiting his court appearance.
When the man was processed, the police custody module didn’t identify any mental health concerns and no monitoring regime was put in place.
At around 11am on Sunday, October 9, the man tried to use a piece of clothing to self-harm while in the police cell.
Officers prevented the attempt and immediately contacted the mental health crisis team. He was assessed and later released from hospital, returning to police custody with a monitoring plan in place.
Medical notes came back from the hospital the next day and police accordingly downgraded his monitoring level from “constant” to “frequent”.
He was moved to the cells at Waitakere District Court to await his court appearance.
Around 10.30am, the man asked officers for a liquid medication that was with his bags.
The man then misused the entire contents of the bottle. Twenty minutes later, an officer discovered he was unresponsive and an ambulance was called.
The IPCA found the two bags brought to the custody unit weren’t adequately processed.
All property must be photographed and entered into the police property system, but only the bags were photographed - not the contents.
The authority ruled the officers’ response to the first self-harm attempt was sound and procedure was correctly followed.
But the second attempt could have been avoided. Providing the medication to the detainee could have resulted in the man’s death, the authority found.
Police had put the medication in a tamper-proof bag. Opening it should have been noted on the man’s custody record, but wasn’t.
Policy also states the medication must be prescribed, labelled with the name of the detainee, and removed from the cell once used.
“Regardless of whether they considered [the bottle] to be medication, the bottle was unlabelled, and they could not be sure of the contents,” authority chairman judge Colin Doherty wrote.
“From a safety perspective, and bearing in mind [the detainee’s] earlier attempt to self-harm, they should have erred on the side of caution and refused to provide the bottle.”
He ruled police failed in their duty of care.
Waitematā relieving district commander superintendent Shanan Gray said police launched a critical incident investigation and this remains ongoing.
”Steps have been taken to improve supervision at the Custody Units in Waitematā District.”
Of the two officers involved, only one still works with the police.
Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.