The family of a woman who was found dead in a Dunedin police cell say they harbour no grudges towards police.
An Independent Police Conduct Authority investigation found the police officers neglected their duty when they failed to follow correct procedures after detaining Juanita Shaw on August 23, 2007.
The 36-year-old died from a methadone overdose in a cell at Dunedin Central Police Station a few hours after she was arrested for failing to appear in court on drug and fraud charges.
One of Ms Shaw's family members said the contents of the IPCA's report, released yesterday, came as no surprise because they more or less covered the same ground as the coroner's finding on her death last year.
The police had been "very up-front" with the family from the start in what had been a tricky situation, the family member said.
"Nothing's going to bring her back, so there is no point harbouring grudges."
The report said once arrested, Ms Shaw was assessed as "in need of care", requiring her to be frequently monitored, after it was noted that she was a heroin addict who received daily methadone medication.
The national police database, which contained a number of alerts about Ms Shaw, including "self-harm" and "suicidal tendency", was not checked.
An officer collected Ms Shaw's methadone medication from a pharmacy and administered it to her shortly after 10.30am.
About 1.20pm, officers walking past Ms Shaw's cell noticed she "did not look well" and then found she was not breathing.
Ambulance officers pronounced her dead on arrival.
A search of her car turned up five used syringes with methadone traces, and a subsequent inquiry police found that Ms Shaw had attempted suicide by overdose on five occasions.
The coroner ruled her death was caused by "inhalation of vomit due to or as a cause of an overdose in methadone".
The IPCA report found there had been significant failings in the assessment of Ms Shaw and officers had not adhered to best practice and the relevant general instructions.
If the national database had been checked, Ms Shaw would have been categorised as needing constant, rather than frequent, monitoring.
The assessment plan for her was not checked or approved by the supervisor, who left soon after to attend to other duties.
Based on the assessment that she be checked frequently, checks were adequate and in line with policy, as was the administration of the woman's prescribed methadone.
However, Ms Shaw was not strip-searched, as she would have been if the database had been checked, nor was she issued with a tear-resistant gown or examined by a police medical officer as per general instructions.
"A strip-search or placing her in a gown might have revealed recent needle marks, evident on Ms Shaw's lower limbs, and signalled the need to call a doctor."
Otherwise, the medical assistance provided by the officers was immediate and appropriate.
The arresting officer, the watchhouse keeper and his supervisor had neglected their duty, but were were not responsible for Ms Shaw's death, the report said.
A police investigation found no criminal liability on the part of the officers involved.
No-one was stood down after the incident, but two Dunedin senior sergeants and a senior constable were counselled and performance plans put in place.
Southern District Commander Superintendent Bob Burns said police accepted they failed in the care of Ms Shaw, and had implemented changes.
For example, methadone was now administered by a doctor or nurse instead of a police officer, and staff received custodial training every two years on assessing and monitoring prisoners in cells.
National headquarters police spokesman Jon Neilson said a police review would bring together existing prisoner management procedures and processes and include IPCA and coronial recommendations, as well as legislative changes.
The recommendations
- Prisoners be woken regularly as part of frequent monitoring.
- Prisoner medication should be seen by a doctor.
- Medication should be administered by a doctor or an appropriately qualified nurse.
- Police consider amending general instructions to include a requirement to conduct a strip search and make sure any prisoner assessed as "in need of care and constant monitoring" is issued with a tear-resistant gown.
