The Independent Police Conduct Authority has found that Police as an organisation, as well as individual officers, failed in their legal duty of care when a man in custody died after a drug overdose in November 2017.
The man was taken into Police custody at the Hawkes Bay Area Custody Unit early on 12 November 2017. When the man was received into custody, he resisted Police attempts to search him, and his health and wellbeing were not properly evaluated due to his agitated state. This lead to Police failing to become aware of warnings on the man's file, particularly that he had suffered a brain injury in the past and did not take his prescribed medication to prevent seizures.
Sometime during the night of 12 November 2017, the man took a large dose of methamphetamine. In the early hours of 13 November, he suffered prolonged and increasingly violent seizures. A post mortem later revealed the man had a fatal level of methamphetamine in his system, and expert medical advice was that he had died of suffocation related to a seizure, probably at about 4.30am.
Throughout the period of his detention, Police failed to make regular checks on the man as required by policy. Several checks were recorded as having been made while the man was having seizures, and after the man had died. An officer placed a breakfast tray in the man's cell at 5.42am on 13 November, yet the man's death was not discovered until about 10am that morning, when an officer tried to wake the man to take him to court.
The Authority found that officers in the custody unit repeatedly failed to perform their duty to care for the man as required by law and policy. Although these omissions were not causative of the man's death, they were serious and inexcusable.
Judge Colin Doherty, Authority Chair, said: "Police policy exists precisely to manage risk and avert the sort of outcome that occurred in this case. The omissions of officers to comply with that policy were likely to cause injury or suffering to a vulnerable adult such as this man."
"Poor leadership, supervision, and support of custody staff contributed to a culture in the custody unit that tolerated a repeated and serious disregard of Police policy and good practice."
The Authority found that there was insufficient evidence to support a criminal prosecution of any individual officer, and that a corporate body such as Police could not be held criminally liable for the potential Crimes Act offences identified. The Authority noted an organisation such as Police could be held criminally liable for the actions of staff who fail to fulfil their obligations under the Health and Safety at Work Act 2015.
The Authority could not determine how the man had accessed the methamphetamine while in custody. Police have since implemented significant changes in the Hawkes Bay Area Custody Unit.