Police were called to a house in the South Auckland suburb of Manurewa in September 2019 because an intoxicated man was screaming, cursing, and banging his head against a wall.
When officers entered, the man was snoring heavily on the driveway, according to the Independent Police Conduct Authority.
Once he woke up, he became aggressive and uncooperative. Officers were told he was possibly under the influence of drugs.
The man was placed in handcuffs, but he then tried to bang his head on a fence and hit his head on the concrete driveway, the IPCA said.
He was taken to the police cells, but the IPCA said he should have been taken straight to hospital.
On arrival at the Counties Manukau District Custody Unit, the man was left in a cell in the prisoner transport truck for 44 minutes, while a decision was made about whether he should be taken to hospital.
The IPCA said this was unacceptable.
The man was eventually placed in a cell but he was not put in the recovery position, as he should have been.
The man was seen by a police doctor over an hour later.
The doctor said the man needed to go to hospital but he lay in a unresponsive state in the cell for another 56 minutes before he was taken.
IPCA chair Judge Colin Doherty said the delay was unreasonable.
“Police policy says that if a person in their care is only partially responsive, police should treat it as a medical emergency and the person should be taken to hospital,” he said.
“Police did not do this and failed in their duty of care.”
Counties Manukau District Commander Superintendent Jill Rogers said police accept the standard of care given to this man was not good enough.
“While the staff were all working with good intent, there was definitely areas for improvement relating to this incident,” she said.
Rogers said significant changes have been implemented to the custody unit and custom-built prisoner transport vans are now being used.
Police were also working closely with the district health board on how best to deal with people who need medical assistance.