On 11 May 2018 Police were advised that a man was suicidal and intended to harm himself. Officers who attended the incident took the man to Hawkes Bay Hospital.
Police left the man in the care of hospital staff. However, the man returned to his home before he could be seen by a psychiatrist. At about 2.40pm Police revisited the man and arrangements were made for him to be assessed at home by mental health professionals.
At about 4.12pm the National Poisons Centre contacted Police, reporting that an unnamed man had called them after consuming a quantity of anti-freeze. Police identified the area where the call had been made and completed a search but did not locate the caller.
At about 10.38pm a member of the public approached a Police officer at a service station and advised there appeared to be a heavily intoxicated man nearby. The officer, who had no knowledge of earlier events, was dispatched to a family harm incident during this conversation and took no further action in respect of the intoxicated man.
At about 8.58am the next day Police were notified of the body of a deceased man in the area where the intoxicated man was reported the previous night. The man was subsequently identified as the man Police had taken to hospital. The cell phone used to contact the National Poisons Centre and a mostly empty bottle of anti-freeze was found at his home address.
Police commenced a practice review and found that:
The Authority agreed with these findings.