Two weeks before he died in a Rotorua police holding cell, chronic alcoholic William Burcumshaw told an ambulance officer "I'm going to drink and smoke myself to death".
Burcumshaw, 52, was known as a "frequent flyer" by ambulance staff because of the number of callouts they had for him. He was known around the CBD as often being heavily intoxicated.
An inquiry into his death on September 19, 2015, by the Independent Police Conduct Authority (IPCA) found that the officers on duty that day should have kept Burcumshaw under physical observation at all times, rather than by CCTV.
In addition, chairman Judge Sir David Carruthers has recommended the Commissioner of Police develop a national protocol between police and Ambulance New Zealand for the appropriate way to deal with drug- and alcohol-affected people or those having a mental health crisis.
An inquest into Burcumshaw's death was held in Rotorua today before coroner Wallace Bain.
Constable Gregory Standen gave evidence as to what happened the day Burcumshaw died. Police responded to a call for help from ambulance staff who were dealing with an "incoherent and heavily intoxicated" Burcumshaw in the City Focus.
Ambulance staff decided not to take him to hospital so police, concerned about leaving him in a public place in that state, took him to the remand centre at Rotorua police station.
He was placed in a holding cell and although heavily intoxicated did not seem to be in any medical difficulty. Officers left to process other arrivals and Burcumshaw was monitored via CCTV.
About 14 minutes later a police medical officer checked Burcumshaw and "nothing alarming was obvious", Standen said.
But 30 minutes later, Burcumshaw was seen to be in trouble and centre staff administered CPR and used a defibrillator, while the ambulance was called. A paramedic later described the medical attention given as "exceptionally well executed".
The ambulance arrived shortly after and paramedics continued working on him but Burcumshaw was pronounced dead at 4.21pm, an hour and 12 minutes after he arrived at the remand centre.
Standen said Burcumshaw was known by his family as being a chronic alcoholic with a "careless attitude to his health and outlook on life in general". He had told an ambulance staff member two weeks earlier that he was going to smoke and drink himself to death.
He had an extensive hospital record with a 300-page medical history from Rotorua Hospital and his ex-wife described him as having ongoing significant health issues, including heart disease.
The pathologist who did the post-mortem examination found Burcumshaw's death was the result of acute mixed drug intoxication with contributory factors including chronic ethanol abuse, hypertension and obesity.
The IPCA investigation found Burcumshaw should have been taken to hospital when he was first detained, that police medical officers should be reminded all assessments of detainees be formal and properly documented and that Burcumshaw should have been kept under physical observation at all times and monitored.
As well as recommending the national protocol between police and ambulance, Sir David said local arrangements between the agencies should be reviewed.
No family attended the inquest.
Coroner Bain said the IPCA and police reports appeared to have identified all relevant issues. He reserved his findings.