Coroner finds ‘inadequate’ medical assessment made before man dies in police cell

A concoction of drugs and associated excited delirium syndrome (ExDS) is the reason why a 21-year-old man died in an Auckland police cell, a coroner’s report has found.

But Coroner Debra Bell found the medical assessment made of Sentry Taitoko at Counties Manukau Police Station was not adequate and that the general practitioner “did not ask the basic questions”.

Taitoko was found unresponsive in the cell and could not be revived by emergency services in the early hours of February 23, 2014.

He had consumed alcohol, cannabis, methamphetamine and a synthetic drug similar to LSD – called 25B-NBOMe – at a friend’s house on the evening of Saturday February 22.

His brother and others found Taitoko at the house sometime after midnight.

They told the coroner he acted strangely, grabbing at his throat, screaming and punching the driveway with his hand.

He was taken home and neighbours called the police with reports of fighting in the street.

Taitoko was taken by four officers into a detoxification cell at Counties Manukau Police Station where he was left unrestrained.

Police claim “the cells were packed” and there would have been in excess of 30 prisoners at the station that night.

One custody officer said: “I could see him in the cell all over the place. I was kind of freaked out a little bit because I had never seen anybody like that”.

Between 1.47am and 2.16am CCTV footage shows Taitoko suffered a total of 202 collapses.

The collapses have been described as him falling from a standing position without breaking the fall with his arms. He was also seen thrashing on the floor and walking into walls.

Mattresses placed on the floor inside the cell to cushion his falls.

Police decided there wouldn’t be increased monitoring of Taitoko because the cell door would need to remain open which would have posed a risk to staff. The cell had CCTV and was in line of sight of staff.

Between 2.18am and 3.41am CCTV footage shows a further 107 collapses, 32 of which were on to a concrete floor or wall.

A registered GP rostered on that night for the station received a call to assess another man. The GP’s name has been suppressed.

On his way to this assessment, he assessed Taitoko for less than two minutes through the cell window.

He reported him thrashing about in the cell.

Police had no information as to what drugs he had taken and the doctor said there was nothing unusual about blood in his cell.

Taitoko stopped constantly collapsing at 3.41am. There is minimal movement of his body and attempts to raise his head, the report said.

Police claim the GP believed sending him to hospital was not necessary because often the hospital would refuse to admit violent prisoners.

The doctor maintains he was not told by police of Taitoko’s head strikes or injuries, but the coroner said this “defies belief” given the number of times it happened.

The GP said it would be difficult for any doctor to examine Taitoko, to obtain his pulse or shine a light in his eyes.

No physical checks were carried out on Taitoko by police between 3am and 5.12am. He was only monitored through CCTV.

CCTV stopped recording between 4.26am and 5.15am because it did not detect any movement in the cell.

Police say it was an extremely busy night and it was assumed he went to sleep.

An officer called for an ambulance at 5.15am but Taitoko was unresponsive.

An Independent Police Conduct Authority review and an investigation by the Health and Disability Commissioner have also been carried out following Taitoko’s death.

Cause of death

Coroner Debra Bell said the cause of Taitoko’s death at the police station was acute intoxication due to the combined effects of methamphetamine and a synthetic drug, with associated excited delirium syndrome.

“25B-NBOMe is a synthetic hallucinogen which may have adverse acute psychiatric and physiological effects, including seizures, hypothermia, and sudden death,” the report said.

“The psychiatric effects may include bizarre, violent and paranoid behaviour.”

Experts contributing to the inquest agreed the synthetic drug has the potential to cause excited delirium syndrome (ExDS) but there is little medical knowledge and understanding of the syndrome.

Some experts who spoke to the coroner said it can be difficult to treat ExDS because the person is usually combative.


Coroner Bell found diagnosis for ExDS is difficult but the medical decision by the GP was not to a standard expected of a medically qualified practitioner.

Taitoko should have been transferred to hospital, the report said.

It was “entirely appropriate” for police to defer to the GP’s advice and police are entitled to rely on that assessment, it said.

“The medical assessment provided was not adequate, nor was it to the accepted standard for a medically qualified practitioner,” Coroner Bell concluded.

They did not ask “the basic questions any medically qualified practitioner should ask”, she said.

“I want to be clear that my finding does not mean that if [the GP] had assessed Taitoko adequately the outcome would have been different.

“The option to transfer was itself fraught with risk, there was no certainty Taitoko would have survived had he been admitted to hospital.

“However this does not change the fact that the medical assessment needed to be at an adequate standard to ensure he had the best chance of survival.

“I make no criticism of [the GP] for not diagnosing that Taitoko was suffering from ExDS. ExDs is difficult to recognise, diagnose and treat.”


Coroner Bell recommends all prisoner’s previous history and behaviour to be accessed by the on-duty medical practitioner.

Police should be fully trained on recognising ExDS and subsequently take that anyone suffering from it to the nearest Emergency Department, Bell suggests.

A memorandum of agreement on this should be made between police, ambulances and EDs.

“Dedicated detoxification centres should be readily available, with trained staff as supervisors,” coroner Bell said.

Bell also requests Counties Manukau police consider a padded cell at the police station.

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