A man who threatened to hurt himself was left in a court cell with fixtures that could be used for self-harm, and was later found dead.
Dwayne Walters, who was 36, was found dead in a court cell in South Auckland's Papakura in May 2015.
He had been arrested for breaching bail, and police had been warned he had threatened to harm himself.
An Independent Police Conduct Authority (IPCA) report released this morning said the poor condition of the court cells were one of the main factors leading to his death. It said there were a number of fixtures in the Papakura District Court cells which could easily be used by people to harm themselves.
It was not an isolated affair - a large number of court cells throughout the country have similar deficiencies
The Ministry of Justice has now carried out a systematic review, developing a plan to identify and fix the problems, IPCA said.
It had also made significant improvements to the Papakura Court cells.
IPCA recommended police adopt a policy in which all reports of suicide threats be recorded on its computer system, and made available for all staff.