The family of a man who died in police custody say his death has helped to push changes for all detainees across New Zealand.
A coroner's report released yesterday found Sentry Taitoko, aged 21 at the time, died from a synthetic drug similar to LSD and the associated excited delirium syndrome (ExDS) at Counties Manukau Police Station in February 2014.
Coroner Debra Bell said a medical assessment carried out by an on-duty medical practitioner on the night was "inadequate" and they "did not ask the basic questions any medically qualified practitioner should ask".
It follows an inquest into Taitoko's death in 2019.
Taitoko's parents Johnna and Michael have responded to the coroner's report of their son, seven years after his death.
"We have found the coroner's report detailed and thorough and [we are] very satisfied with her findings," they said in a statement.
"Our Sentry may not be with us today, but because of him changes and steps are taken to help other detainees around the whole of New Zealand. Even after passing, he's there to help others."
CCTV footage showed he collapsed hundreds of times while in the police cell, was thrashing on the ground, banging his head on concrete and walking into walls.
A GP, who has name suppression, advised against transporting him to a hospital emergency department because of a widespread belief at the time within police that violent prisoners were often turned away by the hospital.
Taitoko died in the cell despite the efforts by emergency services.
"We do feel a bit relieved that we have gotten through the stages of Sentry's inquest and the findings of the coroners report," his parents said in a statement.
"We are also contented that steps have been taken, and changes are being put in place for people like Sentry's condition held in custody.
"[We are] working with the health board, improving methods for transportation, facilities available, electronic records describing the person held, monitoring them including CCTV."
Coroner Bell recommended hospital emergency departments, ambulance staff and police implement a "memorandum" of understanding about the treatment of ExDS.
Bell also recommended police staff be trained to recognise symptoms of people with excited delirium syndrome and suggested the Counties Manukau police district consider padded cells at the station.
Police told the Herald the Counties Manukau police station still does not have a padded cell but they are being installed as part of "new build projects across the country", and are included in new build standards.
"Further work to retrofit padded cells into other main custodial facilities is underway," said Superintendent Jill Rogers.
Updated police policy has a clear definition and description of excited delirium and "enhancement" to the police custodial training.
It was recommended police electronic records of a person's history also be shared with the on-duty doctor.
Rogers told the Herald police medical officers do have access to some electronic details.
"A decision log has been introduced to record all decisions made and the reasons for these ... handover sheets have also been created for the instance where persons in police custody require medical attention, ambulance or hospital treatment."
Police say work with hospital emergency departments is "ongoing" to tackle a "significant increase" in intoxication and mental health issues with people in police custody.
The Independent Police Conduct Authority (IPCA) released two reports in 2015 - one into the death of Taitoko and another into a review of 31 complaints relating to people in custody.
The reports highlighted a number of significant problems with the way in which police deal with people who are detained in police cells.
IPCA chairman Sir David Carruthers said the authority found police breached their legal duty of care to Taitoko in a number of ways.
"The officers who first detained Mr Taitoko should have called for urgent medical assistance.
"There were also numerous other failures that resulted from the failure of police to recognise that Mr Taitoko's behaviour was caused by an extreme and dangerous drug reaction."
The second report found that police officers did not have the necessary expertise and training to deal with some of the challenges presented by the people being held in police cells and they were sometimes required to manage people who should not be in police custody at all.
At the time, Counties Manukau Police District Commander Superintendent John Tims said the report demonstrated the complexity of the situations police were faced with on a day-to-day basis.
"We accept that there were various failings of police responsibility during the time that Mr Taitoko was in custody, and we apologise to his family," Tims said.
New changes include the development and introduction of a new training package for custody officers and a review of training for custody officers to ensure dangerously intoxicated people receive appropriate care while in police custody.
Additionally, police were engaging with hospital and ambulance services to ensure workable solutions are found for dealing with intoxicated or unresponsive people, Tims said.