Police accept they failed in the care of a woman who died in a Dunedin police cell two years ago, and have implemented changes.
Juanita Shaw, 36, was arrested on August 23, 2007 after failing to appear in court on drug and fraud charges.
She later died in a cell after overdosing on methadone and inhaling her own vomit.
An investigation by the Independent Police Conduct Authority (IPCA) released today found officers failed in their duty to look after her.
The officers had "significantly failed" in their assessment of the risk to Ms Shaw and failed to follow proper procedure, the report found.
However, despite giving her a prescribed dose of methadone they were not responsible for her death as she had mostly likely taken methadone before her arrest, it said.
The report found the officers were not criminally liable, but it recommended two senior sergeants and a senior constable be counselled and be the subject of performance plans.
It also recommended the training of all police who managed prisoners should be current and that supervisors should be reminded of their responsibilities.
Police were currently reviewing their prisoner management process, as part of a review of their general instructions.
In addition to that review, IPCA recommended prisoners should be woken regularly as part of frequent monitoring, a prisoner requiring medication should be seen by a doctor, and that medication should be administered by a medical professional.
It also said police should consider including a requirement to strip search prisoners in certain situations and that any prisoners assessed as "in need of care and constant monitoring" be issued with a tear resistant gown. Police accepted IPCA's findings and had already adopted recommendations from the report in Dunedin, Southern District commander Superintendent Bob Burns said.
For example, methadone was now administered by a doctor or nurse, instead of a police officer, and staff had received custodial training around assessing and monitoring prisoners in cells, Mr Burns said.
National headquarters police spokesman Jon Neilson said the police review would bring together existing procedures and processes contained in general instructions and the manual of best practice.
It would include IPCA and coronial recommendations, as well as legislative changes, he said.
These would be subject to consultation on completion and would be introduced over four weeks following this process.
Every year police successfully dealt with or managed more than 150,000 people, many of whom had substance or health issues, Mr Neilson said.
When Ms Shaw was arrested officers assessed her as "in need or care", which required her to be frequently monitored, the report said.
However, they had not checked the national police database, which contained a number of alerts about Ms Shaw including "self-harm" and "suicidal tendency".
Checking this would have indicated Ms Shaw needed to be strip-searched, which would have revealed recent needle marks and signalled the need to call a doctor, the report said.
