On 28 May 2018, Police arrested Mr X and took him to the Gisborne Custody Unit. Arresting officers evaluated Mr X as 'not in need of specific care' and placed him in a holding cell.
Approximately one minute later, Officer A observed Mr X wrapping the hood of his sweatshirt around his neck. Officers removed Mr X from the holding cell and placed him in a monitored cell. They took Mr X's clothing away, handed him a tear-resistant gown and blanket, before leaving him unsupervised in the cell. Officer B then placed Mr X on frequent monitoring.
Thirty minutes later, Officer B observed Mr X wrap the tear resistant blanket around his neck and pull on the ends. Officers removed the blanket from the cell and constantly monitored Mr X. Police arranged for a medical practitioner to assess Mr X and he was subsequently downgraded to frequent monitoring.
Police notified the Authority and investigated the incident. The investigation found that custody staff failed to appropriately evaluate and monitor Mr X, who should have been constantly monitored following the initial suicide attempt.
Police also found that custody staff had missed some routine checks when Mr X was placed on frequent monitoring and were not accurately recording checks in the Electronic Custody Module.
At the conclusion of the investigation, Police provided custodial management training to the officers who were involved with the evaluation and monitoring of Mr X in custody.
The Authority actively oversaw and reviewed the Police investigation and it agreed with the findings.