Coroner Calls for Improved Police Training and Protocols Following In-custody Death Amid Mental Health Crisis

Auckland, New Zealand – A recent coroner’s report has shed light on the urgent need for improved police practices regarding the treatment and monitoring of detainees, particularly following the tragic custody death of Alo Ngata in July 2018. The coroner has called for enhanced training on the use of spit hoods and improved systems to assess prisoners’ consciousness levels to prevent risks such as positional asphyxia.

Ngata, who grappled with mental health and substance abuse issues, including the use of methamphetamine and synthetic cannabinoids, tragically lost his life after a violent encounter that included him severely assaulting 78-year-old Mike Reilly. Reilly, a former country musician, was left unconscious, subsequently spending months hospitalized from his injuries.

The confrontation escalated further when responding officers, finding Ngata unmanageable, resorted to multiple tactical options. Ngata was restrained at both his wrists and ankles and had a spit hood placed over his head before being transported to the Auckland Custody Unit. Once there, he was carried into a cell and left prone on the floor, still hooded.

A critical turn of events unfolded when, minutes later, officers observed that Ngata hadn’t moved. Their attempt to revive him was unsuccesssful, and Ngata was transported to a hospital where he remained unresponsive. Life support was withdrawn three days later. Subsequent investigations revealed multiple lapses in duty of care by the custody staff.

The handling of Ngata from his arrest through his transportation and care in police custody highlighted a severe discrepancy in police protocol and detainee safety. The Independent Police Conduct Authority noted that while the initial arrest was handled appropriately given Ngata’s violent resistance, the oversight and subsequent care by custody staff fell dramatically short of standards.

In 2020, the authority’s report highlighted these systemic failures which led to a tragic loss of life and instigated an inquest hearing. Concerns were particularly noted about the continuous application of the spit hood and restraints, despite Ngata’s compromised physical state. Further examinations suggested that positional asphyxia, exacerbated by these restraints and potentially by the spit hood, were contributory factors in Ngata’s death.

The coroner emphasized that Ngata’s condition should have prompted an immediate medical assessment and potential hospitalization, instead of being placed in a detention setting that clearly failed to accommodate his acute needs. The report recommended substantial reforms in monitoring practices for similar high-risk detainees.

Toxicological findings confirmed the presence of significant levels of methamphetamine, which the coronorne emphasized likely contributed to Ngata’s erratic behavior and fatal health decline. The post-mortem examination further noted brain damage and abnormal heart rhythm as the primary causes of death, with restraining methods and possible suffocation being significant contributors.

In response to the findings, law enforcement officials are tasked with reevaluating their training procedures concerning the handling of emotionally disturbed or substance-impaired individuals. These revisions aim to better equip officers to recognize medical or mental health crises and respond more efficaciously and humanely, potentially saving lives in similar future incidents.

The tragic narrative of Alo Ngata serves as a poignant reminder of the essential balance required between enforcing law and ensuring the welfare and rights of those in custody. The suggested improvements in police training and protocols reflect a societal call for accountability and change that aims to prevent such occurrences in the future.