Police officers responsible for a woman who was found dead in a Dunedin police cell after inhaling her own vomit failed to follow correct procedures, an Independent Police Conduct Authority (IPCA) investigation has found.
Juanita Shaw, 36, was arrested on August 23 after failing to appear in court on drug and fraud charges, and was taken to the Dunedin Central Police Station, an IPCA report said.
She was assessed as "in need of care", requiring her to be frequently monitored, after it was noted that she was a heroin addict who received daily methadone medication.
The report said that the national police database (NIA), which contained a number of alerts about Shaw, including "self-harm" and "suicidal tendency", was not checked.
An officer collected Shaw's methadone medication from a pharmacy and administered it to her shortly after 10.30am. About 1.20pm officers walking past Shaw's cell noticed she "did not look well" and then found she was not breathing.
Ambulance officers pronounced her dead on arrival.
A search of her car turned up five used syringes with methadone traces, and a subsequent inquiry police found that Shaw had attempted suicide by overdose on five occasions.
The coroner ruled her death was caused by "inhalation of vomit due to or as a cause of an overdose in methadone".
The IPCA report found there had been significant failings in the assessment of Shaw. Had the NIA been checked, alerts for "self harm" and "suicidal tendencies" would have indicated she required constant monitoring, the report said.
The NIA would have also indicated that Shaw needed to be strip-searched, which would have revealed recent needle marks and signalled the need to call a doctor, the report said.
Police rules required those considered "in need of care" to be examined by a medical officer, which Shaw was not, and to be issued with a gown, which Shaw was not.
The report said the failings of the officers involved amounted to a neglect of duty, but that they were not responsible for Shaw's death.
"Police administered only the prescribed dose of methadone in accordance with the pharmacist's instructions ... there is an assumption Shaw had taken methadone before her arrest," the report said.
The IPCA recommended prisoners should be woken regularly as part of frequent monitoring, a prisoner requiring medication should be seen by a doctor, and that medication should be administered by a medical professional.
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