Police failed in their duty of care to a man who attempted suicide in a court cell and died several days later, the Independent Police Conduct Authority has found.
The man was taken into custody for breaching bail conditions on 7 October, 2017. Four days later taken to a hearing at Tauranga District Court, and at midday was found unconscious in a cell.
He died a few days later in hospital.
The IPCA said the initial evaluation of the man was inadequate and there were inconsistencies in the handover from outgoing custody staff to incoming staff.
It said clothing with clear potential for self-harm should have been removed as per police policy, and despite the man's history of self-harm he was not checked on for more than 20 minutes.
In the preceeding four days, he had been checked on regularly.
The Authority accepted that the court cell environment was different from the police station, that detainees were frequently moved, and police officers were under-resourced at the court that day.
It also found that once the man was discovered unconscious, police provided him with timely and appropriate medical assistance.
Police accepted the findings and said they had met with the family and were providing ongoing support.
"We take our responsibility in regard to the management and care of people in our custody seriously, and an outcome where someone is injured in our custody and later dies is tragic," Bay of Plenty District Commander Andy McGregor said.
"The issues raised in the report in regard to the failure to follow processes have been raised with the staff involved and the need to adhere to the policies in place has been reinforced."
McGregor said work on a national review, looking at the safety of prisoners in police custody, is ongoing and the IPCA findings would feed into this work.
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