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Home / Publications and Media / 2015 Media Releases

IPCA review identifies significant problems in Police custody practices 

27 March 2015 

In releasing two reports today, the Independent Police Conduct Authority has highlighted a number of significant problems with the way in which Police deal with people who are detained in Police cells.

The first report, entitled “Review of Police Custodial Management”, is a review of 31 complaints and incidents that have been referred to the Authority over the last three years, combined with more general enquiries undertaken by the Authority.

“From the moment they take custody of a person, Police have a legal duty of care to take all reasonable steps to ensure that person’s wellbeing while they are in custody,” said Judge Sir David Carruthers, Independent Police Conduct Authority Chair.  

“This report has found that, often through no fault of their own, Police officers do not always fulfil that duty of care.   They do not have the necessary expertise and training to deal with some of the challenges presented by people being held in Police cells, and they are sometimes required to manage people who should not be in Police custody at all.” 

The report describes the process that Police are expected to follow in assessing at-risk people and determining the steps required to reduce that risk.  While this process generally works well, the report identified a number of flaws in it.

"Risk assessments are not always done robustly or quickly enough, so that officers do not identify relevant risk factors,” Sir David said.  

“When a person is found to be at-risk, officers sometimes fail to implement strategies to manage that risk – for example, by not monitoring the person frequently enough or calling a doctor or taking them to hospital.   As a result, there are too many instances of attempted suicide, self-harm, and failures by Police to seek attention for those that present with medical conditions.”

“These deficiencies are not surprising. Police cell-blocks can be very busy. Staff are often dealing with difficult and uncooperative people who have issues that Police have neither the skills not the training to deal with appropriately.”

The report has particularly highlighted the problems confronted by Police in dealing with people in custody who have mental health problems, or are intoxicated. 

The Authority has found that people with mental health problems are often detained and taken to a Police cell, not because they have committed an offence, but because they require a mental health assessment and there is no mental health worker immediately available to undertake that assessment in another location.

“In some of the cases the Authority examined, their detention by the Police was unlawful,” Sir David said.  “In other cases the person’s initial detention was lawful, but they were subsequently detained for longer than the six hour period permitted by law.”

“The Authority considers that Police cells are entirely unsuitable for those in mental distress.  They are a harsh, noisy and uninviting environment.  The problems arising from custody officers’ lack of skills and training in dealing with at-risk prisoners are accentuated when they are dealing with people who are in custody because they are mentally distressed. While officers try to deal with them patiently and professionally, the prisoners’ mental distress is often made worse and they sometimes suffer long term harm.”

“Unless a person experiencing a mental health crisis, is violent or poses an obvious and immediate threat to the safety of others, all practicable steps should be taken to avoid having them in Police cells. It is unacceptable that, in many Police districts, this is the standard default inter-agency response to a public call for Police assistance to deal with a person experiencing a mental health crisis. Police should not be left in the position of dealing with vulnerable and distressed people in this way. Other more appropriate interagency responses must be developed,” Sir David said.

The second report released by the Authority today is the result of an investigation into the death of a young man in Police custody. 

This report exemplifies the problems set out in the Authority’s review of Police custodial facilities.

In the early hours of 23 February 2014 Sentry Taitoko was taken into Police custody after he was arrested for a breach of the peace. Mr Taitoko was heavily intoxicated, had taken drugs and was acting in a violent way that posed a risk to himself.  

After arriving at the Counties Manukau District Custody Unit at about 1.45am, Police put Mr Taitoko in a cell and officers periodically monitored him. They did not undertake a formal risk assessment until over an hour later.

During the night officers witnessed Mr Taitoko rolling on the ground and thrashing his arms and legs about.   Over a period of half an hour from 1.47am to 2.16 am, the CCTV footage shows him falling and hitting his head on the concrete walls or floor of the cell 83 times.  Over the next hour, he hit his head around another 31 times.  Over time the walls of the cell became smeared with blood from Mr Taitoko’s nose and from grazes on his body.

From around 4:00am onwards Mr Taitoko stopped any violent movements and started lying on his right-side and his stomach.  Although he had been made subject to frequent monitoring after his formal risk assessment (which requires checks at least 5 times per hour), he was not checked at all for about 50 minutes after 4.26am other than by way of CCTV observation.  

At 5:15am one of the custody officers noticed blood on Mr Taitoko and called for another officer to come and look at him. At this time the officers opened the cell door and found Mr Taitoko’s  breathing to be short and gargled and his eyes rolling back in his head. An ambulance was called and offers began monitoring his breathing.  However, attempts by paramedics to resuscitate Mr Taitoko were unsuccessful. Mr Taitoko was pronounced dead at 6:10am.

The Authority has found that Police breached their legal duty of care to Mr Taitoko in a number of ways.

“The officers who first detained Mr Taitoko should have called for urgent medical assistance,” Sir David said.   “There were also numerous other failures that resulted from the failure of Police to recognise that Mr Taitoko’s behaviour was caused by an extreme and dangerous drug reaction.  The custody sergeant should have called an ambulance or arranged for him to be taken to hospital when he arrived at the Police cells; custody staff should have undertaken a prompt risk assessment; and Mr Taitoko should have received continuous monitoring in view of his condition.”

The Authority has noted that, at the request of the custody sergeant, a Police doctor looked at Mr Taitoko through the cell window at 3.21am, although he did not enter the cell or examine him.  The Police doctor said that Mr Taitoko was too violent to be taken to hospital and at 4.05 am he confirmed his view that Mr Taitoko did not need to go to hospital. 

“Although the Police should have taken Mr Taitoko to hospital at an earlier stage, they cannot be criticised for failing to do so after they received this medical advice,” Sir David said.  “It was reasonable for them to rely upon that advice.”

“These two reports released by the Authority demonstrate significant problems with Police custodial management.  The Police themselves have recognised the difficulties they confront in dealing with many of those who come into custody and have been working hard in many Districts to address them.”

“However, these problems are not solely the result of Police processes. They reflect an inter-agency and community failure to deal appropriately with mentally impaired and intoxicated people.  The Police simply do not have the expertise and training to respond to the demands placed on them in this respect. The Authority is highlighting these problems in order to encourage public and political debate about how improvements can be made.  Police cannot, and should not be expected, to remedy this on their own,” Sir David said.

“The Authority has made a number of recommendations in relation to these issues.  These include the introduction of more systematic and nationally consistent training of officers working in custodial facilities, and more specific guidance to custody staff about the monitoring of prisoners.

“The Authority has also recommended that Police work with the Ministry of Health and other agencies to look at ways of minimising the number of mentally impaired people who are taken into Police custody for a mental health assessment, and to explore ways to improve the current methods of dealing with intoxicated people,” Sir David said.

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