An investigation into the death of a man in custody in the former Rotorua police cells has found that several officers failed in their duty of care towards him.
The Independent Police Conduct Authority has found that policies and procedures in place at the time would have been sufficient to have prevented the death, but were not followed.
Anthony McGuire, who had been arrested while drunk, hanged himself in May 2008.
Mr McGuire had been charged with assaulting his former partner and driving with excess breath alcohol.
He was not searched in line with standard policy when arrested, nor was he searched by the two custody officers who put him in the cell.
Mr McGuire was put in custody just before 5.30pm. It was not until almost 9pm that another prisoner saw him hanging from his cell door after police failed to take his shoe laces.
CCTV footage showed two custody officers walking past the cell 14 times in a three-and-half-hour period, but neither entered the cell to check on Mr McGuire.
No recommendations made
In its report released on Wednesday, the IPCA says the police watchhouse and custody areas were not appropriately staffed and officers were inadequately supervised.
The authority's chair, Justice Lowell Goddard, says that if Mr McGuire had been assessed for risk and monitored properly, he would not have had the chance to commit suicide.
The authority has, however, made no recommendations, noting in its report that disciplinary action was taken against the officers and independent legal advice was sought as to whether there was any criminal liability on their part.
It says Rotorua now has a new custody facility and the level of supervision has been improved.
Rotorua police area commander Inspector Bruce Horne says custodial management processes have been strengthened following Mr McGuire's death.
Inspector Horne says prisoners are now constantly monitored by line of sight in a new facility, where electronic documents are approved by supervisors and prisoner property, including shoes, are removed.