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Self-harm in Counties Manukau Police District Custody unit

27 November 2018


The Independent Police Conduct Authority has completed its investigation into two self-harm incidents, involving the same female prisoner, at the Counties Manukau Police District Custody Unit (DCU) in October and November 2017. The Authority found that Police failed to appropriately receive, evaluate, and monitor the woman while she was in Police custody.

On 24 October 2017, Police arrested the woman for breaching her bail conditions. Police staff left the woman unattended in a holding cell in the DCU, and she proceeded to tie her sock around her neck, in an apparent attempt to asphyxiate herself. The woman subsequently fell to the floor, where she remained still and unnoticed by staff for over five minutes.

When staff found the woman she was breathing but unresponsive, and they placed her in the recovery position. After re-entering the cell, they discovered the sock around her neck and called an ambulance. The woman was later sedated and placed in intensive care. She was discharged from hospital two days later.

On 18 November 2017, Police again arrested the woman and took her to the DCU. The woman was placed in a cell with another female prisoner, who activated the cell call button 30 minutes later after noticing that the woman did not appear to be breathing.

Police staff took several minutes to respond as they did not notice the call alert. The woman had fastened her bra around her neck. She was transported to hospital and later discharged by medical and psychiatric staff into the care of Corrections staff.

"During the course of its investigation, the Authority determined that there were a number of failings by Police staff during these incidents relating to the adequacy of communication between Police staff, the quality and accuracy of their risk evaluations, and the levels of monitoring that the woman was subject to. It is evident that in both instances Police did not sufficiently fulfil their duty of care to her" said Authority Chair, Judge Colin Doherty.

Public Report

Self-harm Police custody (PDF 557 KB)

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