Police "failed in their legal duty of care" when a man who was arrested died in the Hawke's Bay Custody Unit in 2017, an Independent Police Conduct Authority (IPCA) investigation has found.
A statement from the IPCA said when the man arrived in custody, his health and wellbeing were not properly evaluated due to his agitated state.
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Police acknowledged the IPCA findings, and say significant changes to practice have been made - such as training and improving the way custody staff are supervised.
The man, who took a large dose of methamphetamine, had not been checked on regularly by police as required by policy.
A police officer placed a breakfast tray in the man's cell at 5:42am on November 13, but he was not discovered dead until 10am that morning, when he was due to appear in court.
While failure by police did not cause the man's death, they were "serious and inexcusable", the authority found.
Authority chair Judge Colin Doherty said failure "to comply with the policy were likely to cause injury or suffering to a vulnerable adult such as this man".
Police however could not be held criminally liable for potential Crimes Act offences identified, as there was insufficient evidence to support a criminal prosecution of an individual officer.
The IPCA could not determine how the man had accessed the methamphetamine while in custody.
Eastern District Commander Spt Tania Kura said it was a tragic incident.
"I am very disappointed that on this occasion we did not follow the standards and policies to keep detainees safe.
"The staff acknowledge they failed to adhere to the procedures."
WorkSafe is not investigating the incident.
"Our focus is on caring for people and individuals and ensuring there are processes and systems in place to support this approach," Spt Kura said.
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