An inquest has been told the police failed to tell a doctor a young man had hit his head more than two hundred times against the walls and floor of the South Auckland police cell he later died in.
Sentry Taitoko, 21, who was high on drugs, died in a cell at Counties Manukau Police station in February 2014.
His inquest yesterday was told the doctor who was asked to assess him wasn't told key information before deciding whether to send Mr Taitoko to hospital.
Mr Taitoko was placed in a cell at the Counties Manukau police station after consuming methamphetamine, alcohol and LSD over several sleepless days.
He was high on drugs and acting aggressively when he was arrested for breaching the peace on 22 February, 2014.
The cell he was placed in - a suicide watch cell - had no furniture and was monitored by CCTV cameras.
Throughout the night, he hit his head repeatedly against the walls and floor.
At 3am a doctor, who RNZ cannot name, received a call from the Counties Manukau station asking him to come in to assess another prisoner who had injured their hand.
"As I was preparing to see the first patient, Sergeant Turvey asked me if I would have a quick look at another patient on the way down the corridor."
That other patient was Mr Taitoko, who the doctor briefly assessed about 3.20am.
His aggressive behavior meant the doctor was unable to go inside his cell and conduct a physical assessment.
By that point in the night, Mr Taitoko had hit his head more than 200 times.
The doctor told the inquest the police officers present did not tell him that was the case.
"I asked if he'd received any head injuries and I was told he had not."
The doctor said in the two minutes he spent observing Mr Taitoko he didn't appear to hit his head.
Forty minutes later, after assessing two other prisoners, the doctor briefly walked past Mr Taitoko's cell again.
"It appeared to me, when I saw him a second time, that his behaviour had become even more quiet and less violent. He appeared to be settling down."
He said this was reassuring.
"That was the behaviour we'd observed many times, or I had observed many times, with intoxicated and drug affected prisoners. They generally acted aggressive at first, eventually calmed down and slept it off and made a full recovery."
Both the doctor and two sergeants then agreed there was no need to send Mr Taitoko to Middlemore Hospital.
"My belief was that Mr Taitoko would be safe left in the police... custody with regular and close monitoring. My expectation was that should his condition deteriorate they would either let me know, or if it deteriorated significantly call an ambulance and transfer him to hospital."
But the doctor said if he'd received more information from the police, things would be different.
"If I had known Mr Taitoko had received so much blunt trauma to his head, I feel I would've come to an entirely different decision... to send him to hospital."
The inquest was told that both the police and the doctor believed, at the time, Middlemore Hospital wouldn't have admitted Mr Taitoko because of his uncontrollable, aggressive behavior.
"That view was incorrect, but it had never been passed on to us, so we didn't know that these prisoners could be medically sedated and dealt with etc., we did not know that at that time."
The doctor said after Mr Taitoko's death, he met with Middlemore Hospital staff and police to discuss what could be done in similar cases.
"As a consequence of that, we've had a much more collegial relationship and a much better understanding of what our medical colleagues at the hospital can do and so that has also led to us being able to transport prisoners there a lot... easier and with a lower threshold."
The doctor said he is not aware of Middlemore Hospital turning away a prisoner since Mr Taitoko's death.
The inquest will continue at the Auckland District Court this morning.