"When a person dies while he or she is in custody, it has a serious impact on both their family and the police officers involved."
Carruthers said that public confidence in the police may also be affected by deaths in custody.
"While not all deaths in custody are foreseeable or preventable, in some cases the actions or omissions of police staff may be a contributing factor," he said.
Assistant commissioner Nick Perry responded by saying that police had already embarked on many of the recommendations listed in the IPCA report.
Police had spent $3 million suicide-proofing cells, removing hanging locations. They had learnt the hard way that pillowcases and blankets could be ripped and used as nooses.
He said: "Every death in custody is a tragedy and we don't want any to occur. We are dealing with people here who have consumed alcohol and drugs, there is often a psychological issue. At least 50 per cent had serious health issues."
Perry said just two people had died in police custody in the past three years.
"There is always that risk there, but frankly, expecting our officers to carry out a health assessment in the midst of trying to subdue somebody is totally unrealistic."