Content warning: This story discusses graphic details of death and self harm.
The mother of a young man who died in an Auckland police cell six years ago says it has been a long wait for answers.
A coronial inquest into the death of 21-year-old Sentry Taitoko concluded in the Auckland District Court this afternoon.
Taitoko died after repeatedly hitting his head on the floor and walls of a suicide prevention cell in the Counties Manukau Police Station during a bad trip on LSD in February 2014.
An inquiry into his death has faced several delays over the years; the latest being an adjournment last October when the Skycity Convention Centre fire caught fire nearby.
This afternoon, his mother Johnna Taitoko told the coronial court lessons should be learnt from her son's death to prevent others dying in the same way.
"The main concern we would like to address is to prevent such sad circumstances from this happening to others and to also put in place a back-up plan of this type of incident that happened to our son Sentry.
"It's been six years. It's been a long struggle for us to wait for answers. We're hoping that the law will cover everything that's happened to our boy."
Ms Taitoko, who watched the proceedings remotely from Sydney today, said she believed changes had been made as a result of her son's death.
The crux of the inquest has been whether or not Taitoko should have been taken to an emergency department for treatment that night.
The 21-year-old was arrested for breaching the peace at his brother's house in Manurewa after consuming a cocktail of drugs over a long period of no sleep.
The court has heard it took four police officers - in quite a struggle - to place the young man in the suicide prevention cell that night.
Taitoko hit his head on the floor and walls of the cell dozens of times over the course of the night before appearing to become subdued and later dying.
An officer had asked a passing doctor - who has name suppression - for an opinion about the young man's condition and was told he would be fine if regularly monitored.
Last year, the doctor told the inquest he was not told about Taitoko's head banging and if he had known about it he would have suggested he be taken to hospital.
Today, associate professor Warren Smith told the inquest that police clearly failed to recognise the seriousness of Taitoko's condition.
"This is the tragedy. The tragedy is that Mr Taitoko was considered to be settling down to the degree that it would be okay to come look at the next morning but in fact far from settling down he was starting to die and that fact was overlooked."
Smith said that while there would have been an inherent risk in transferring the young man to an emergency department, it was there he would have received life-saving treatment.
"A transfer could constitute a risk and as in any medical decision you're balancing the risks against the advantages. Here you have a person repeatedly injuring himself because he's unable to kneel, sit or stand without losing consciousness."
Emergency medicine specialist Dr Henry Gresham later told the inquest Taitoko was very clearly at the "far end" of the spectrum of a condition called excited delerium syndrome.
He said there was much lower awareness of the syndrome in 2014 and the point of holding such inquiries was to determine what could be learned from such a tragedy.
Coroner Debra Bell thanked Taitoko's whānau for attending the inquest at its conclusion this afternoon.
She apologised for the delay; saying while it was the nature of the jurisdiction she was in no way making an excuse for the more-than six years it had taken.
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