A Coroner is critical of the medical assessment given to a man who died while in custody in 2014.
Sentry Taitoko, 21 was found unresponsive in a police cell at the Counties Manukau Police Station on 23 February. Resuscitation efforts failed.
He died from acute intoxication from the combined effects of methamphetamine and probable synthetic drugs with associated excited delirium syndrome.
Coroner Debra Bell said the medical assessment provided by a doctor, who has name suppression, was not adequate or to the accepted standard for a medically qualified practitioner.
She said the doctor did not ask the questions a medically qualified practitioner should ask.
Coroner Bell said her finding did not mean that, had Taitoko been adequately assessed, the outcome would have been different.
She said transporting Taitoko to an emergency department may have been fraught with difficulty but it was clear that had the doctor known Taitoko had suffered from head strikes he would have had him transferred to hospital.
The Coroner said there was no certainty he would have survived but it should have been recognised that Taitoko required a full medical workup and advanced medical treatment, which would be worth any perceived or real risk to him.
The Coroner has recommended electronic records compiled by police regarding all details of a prisoner's history and behaviour be made available to doctors called to attend prisoners in police custody.