There were several failures in the police care of a heavily intoxicated man who died after hitting his head more than 100 times while in a police cell, the police watchdog has found.
Sentry Taitoko, 20, died on February 23 last year after being arrested for breach of the peace.
Today the Independent Police Conduct Authority (IPCA) released two reports -- one into the death of Mr Taitoko and another into a review of 31 complaints relating to people in custody.
The reports have highlighted a number of significant problems with the way in which police deal with people who are detained in police cells.
IPCA chairman Sir David Carruthers today said Mr Taitoko arrived at Counties Manukau District custody unit about 1.45am and was periodically monitored.
During the night officers witnessed Mr Taitoko rolling on the ground and thrashing his arms and legs about.
Over the period of half an hour, CCTV footage showed him falling and hitting his head on the concrete floor and walls of the cells 83 times.
Over the next hour, he hit his head another 31 times.
"Over time the walls of the cell became smeared with blood from Mr Taitoko's nose and grazes on his body," Sir David said.
At 5.15am an officer found his breathing to be short and gargled and his eyes rolling back in his head.
Attempts to resuscitate Mr Taitoko were unsuccessful and he was pronounced dead at 6.10am.
Sir David said the authority found 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.
"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."
A police doctor looked through the cell window at 3.21am, but said he was too violent to take to hospital.
Police could not be criticised for failing to do so after receiving that medical advice, Sir David said.
No single officer breached Mr Taitoko's care enough to warrant criminal charges, he said.
The second report found that police officers did not have the necessary expertise and training to deal with some of the challenges presented by the people being held in police cells and they were sometimes required to manage people who should not be in police custody at all.
"When a person is found to be at-risk, offenders 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," Sir David said.
"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."
The authority recommended 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.
Counties Manukau Police District Commander Superintendent John Tims said the report demonstrated the complexity of the situations that police were faced with on a day-to-day basis, particularly when dealing with people affected by alcohol, drugs or suffering mental distress.
"We accept that there were various failings of police responsibility during the time that Mr Taitoko was in custody, and we apologise to his family," Mr Tims said. "The report makes a number of recommendations and acknowledges that a number of changes have already been implemented to ensure police are better equipped to deal with those experiencing these problems."
New changes include the development and introduction of a new training package for custody officers and a review of training for custody officers to ensure dangerously intoxicated people receive appropriate care while in police custody.
Additionally police were engaging with hospital and ambulance services to ensure workable solutions are found for dealing with intoxicated or unresponsive people, Mr Tims said.
By Rebecca Quilliam of NZME. News Service
