A man who died in a stream might have been saved if police took a concerned caller seriously, a Coroner has found.
Scott Tamarakei Matthews, 36, drowned last year in Meola Creek at Westmere, Auckland, after a drug relapse.
On the morning of his death, Matthews was spotted by a member of the public, breaking branches and yelling. The police were called at 5.36am - but no action was taken.
Other members of the public spotted him repeatedly launching himself into the Motions Rd creek. But despite concerns, police were not called again until 7am. When officers arrived they found Matthews dead.
"There is little doubt had police responded earlier they may have found him and prevented his death two hours later," Coroner Tania Tetitaha said in a recently released decision.
Coroner Tetitaha said at the time of his death Matthews was struggling from a personal crisis that had resulted in him relapsing.
He was released from prison in 2016 and, as a part of his release plan, was required to attend alcohol and drug counselling.
But he failed to do so and no further follow-up was taken by Corrections.
Earlier intervention and follow-up by Corrections may have also helped to avoid the drug-taking which led to Matthews' death, Coroner Tetitaha said.
"People are vulnerable after their prison release and the chief cause of prisoner and ex-prisoner death is substance abuse."
Tetitaha said she did not agree with the police justification for their lack of action.
"The unavailability of police units to respond is a resourcing issue. Neither of these issues can be used to retrospectively justify the failure to respond to the 111 call at 5.36am. This is especially when the caller identifies someone who is distressed.
"I have been considering making a recommendation that the Independent Police Conduct Authority (IPCA) investigate this death including the adequacy of the police response to the 111 call."
She said a draft of her recommendation had been sent to the IPCA for comment.
"They advised that they had already considered the matter... I was advised that a police investigation identified inadequate service in managing the call, a breach in standard operating procedures and a failure to carry out duties. It further refers to appropriate employment outcomes with staff involved."
Coroner Tetitaha ruled that Matthews' death was caused by unintentional drowning.
She sought a report from the police on the outcome of their investigation.
"I also asked the police to meet with the family to discuss the outcome of their investigation.
"Inquiries by my officers with the family have indicated there is no further action required. Given these responses, I have determined that no recommendations are required."
* This story originally appeared in the New Zealand Herald.