Photo: RNZ / Patrice Allen
Sentry Taitoko, 21 was found unresponsive in a police cell at the Counties Manukau Police Station on 23 February. Resuscitation efforts failed.
He died from acute intoxication from the combined effects of methamphetamine and probable synthetic drugs with associated excited delirium syndrome.
Coroner Debra Bell said the medical assessment provided by a doctor, who has name suppression, was not adequate or to the accepted standard for a medically qualified practitioner.
She said the doctor did not ask the questions a medically qualified practitioner should ask.
Coroner Bell said her finding did not mean that, had Taitoko been adequately assessed, the outcome would have been different.