Police failings in care of a man who self-harmed in Police custody unit
The Independent Police Conduct Authority has found that there were Police failings in the care of a man who self-harmed while in Police custody at the Auckland Custody Unit (ACU) on 6 October 2023.
At about 10.30am on 5 October 2023, members of the public overpowered the man after a stabbing in an Auckland dairy. Police arrested the man who said he was trying to reach heaven. The man was acting aggressively and erratically and tripped, falling to the ground while attempting to escape. Given his behaviour, the officers were unable to determine whether he had any injuries. We are satisfied that there was no indication he needed urgent hospital attention and that it was appropriate to take him to the ACU where he could then be medically assessed.
Upon arrival at the ACU, the man got out of the patrol car and attempted to flee. Four officers brought the man under control and escorted him toward the designated search area. One of the officers tripped the man, unnecessarily, causing him to fall to his knees.
The officers say the man was heightened, very strong and they believed he was under the influence of drugs. Three officers held the man in a standing position against a wall in the search area. One of the officers held him by the hair then pulled him off balance and lowered him to a prone position on the floor. While we accept the man was generally behaving erratically, footage indicates he was not offering any significant resistance while being held against the wall. Therefore, in our assessment, it was unnecessary for the officer to hold him by the hair and take him to the ground at this point.
The Police sergeant in charge of the ACU thought the man was suffering some kind of psychosis or "excited delirium" and believed he posed a risk to staff. It was decided that it was necessary for the man to be placed into a restraint chair. We accept that the use of the restraint chair was justified. However, it was unreasonable for the man to have remained handcuffed while in the restraint chair.
Once in the chair, a custody officer completed an evaluation of the man's physical and mental health, as required when detainees are brought into custody units. In our view, this was primarily treated as a procedural step rather than a considered assessment of risks and welfare concerns. There was other relevant information that could have been included.
While the man was monitored in the restraint chair, the sergeant phoned the Police doctor who advised that if the man were experiencing 'excited delirium', he would need to be taken to hospital. An ambulance was called. A custody officer then became concerned the man was quickly deteriorating, so the ambulance was called again, and asked to attend immediately. At about 12.40pm, ambulance officers took the man to hospital under sedation.
At around 5pm, the man was discharged from hospital and returned to the ACU. Hospital discharge papers noted that he was presenting well and did not appear to be an increased risk of harm to himself or others.
The sergeant in charge of the night shift observed the man was not talking, was very unsteady on his feet and needed assistance to walk. He was aware the man had been sedated and assessed him as being extremely intoxicated. He arranged for him to be further assessed by the Police doctor, and by a mental health doctor. This was a good decision.
The Police doctor advised the man could be placed on 'frequent' monitoring, requiring him to be checked five times an hour, rather than being constantly monitored. In our view, given the advice of the health professional, it would not be fair to criticise the sergeant's decision to downgrade the monitoring regime.
Over the course of the night, custody staff recorded that they completed 80 checks on the man. More than half of these checks do not appear to have been conducted in line with Police policy as officers observed the man on the CCTV screen, rather than physically going to the cell.
The custody team, who had dealt with the man the previous day, returned in the morning and were told there had been no issues with the man overnight. At about 7.30am, the man removed his overalls, mostly keeping a blanket wrapped around himself. We accept that occasionally detainees choose not to wear clothing while in the cells. However, in our view, this should have prompted some concern about the reason for this.
Throughout the morning, custody staff recorded that they completed 30 checks on the man. Some of these checks involved talking to him over the intercom inside his cell, looking at the CCTV screen, or officers checking on the man from their workstations. In our view, these checks were inconsistent with policy as the officer did not go to the cell.
At about 10.54am, an officer went to check on the man and found him unresponsive. Officers promptly commenced first aid. The man was taken to Auckland Hospital and died three days later, as a result of self-harm.
From the footage, it is apparent to us that the man was listening for, and observing, staff movements looking for an opportunity to self-harm. While we cannot say that this tragic incident could have been prevented, proper checks would have reduced the opportunity for it to occur.
We acknowledge that this incident involves the loss of life and extend our condolences to the man's family and friends.
