Coroner casts ‘considerable doubt’ on police account of Alo Ngata’s death

By and is republished with permission.

Since Alo Ngata’s death in 2018, police have maintained that he was violent and non-compliant while in custody. But a coronial investigation released today reveals Ngata was “poorly monitored” and police did not recognise his “severely reduced consciousness”.

Alo Ngata. (Source: Supplied)

Alo Ngata stopped breathing while in police custody after he was left face down in a cell with a spit hood on. He was declared brain dead in hospital and died three days later.

The 29-year-old was arrested on July 1, 2018, after randomly assaulting an elderly man in Central Auckland while suffering a psychotic episode.

After an intense struggle with police where he was tasered, pepper sprayed, and restrained, Ngata was transported to the Auckland Custody Unit where, sometime later, he was found without a pulse.

Since his death and throughout subsequent investigations, police have maintained that Ngata continued to act violently while in custody.

Shortly after announcing his death to the public in 2018, Superintendent Kathryn Malthus said, “This was a man who was still resisting police interaction with him after he was restrained and put into the vehicle. When he was taken out of the vehicle, he was still resisting with police”.

But Coroner Matthew Bates’ findings today in relation to the 29-year-old’s death brings into question that version of events.

In his report, the coroner states he has “considerable doubt regarding the degree to which Alo was said to be resisting” after his arrest.

He refers to CCTV footage which “gives the impression that Alo was semi-conscious and unresponsive” while being carried to his cell.

Then, once in the cell, he said it is “more likely than not that Alo was fully unconscious”.

Bates said he accepts that “rightly or wrongly, officers were responding to what they perceived to be resistance”, but added that if Ngata had been “constantly and vigilantly monitored as policy required”, officers may have noticed he was suffering from a medical emergency sooner.

Alo Ngata and his family.
Alo Ngata and his family. (Source: Supplied)

The family’s lawyer, Marie Dyhrberg KC, said the coroner was fair in his identification of “major failures” in Ngata’s care.

“The lack of proper monitoring, proper supervision, so that those who were looking after him… could not tell if he was distressed, if he was breathing.”

She said police descriptions of Ngata continuing to be aggressive in custody “was not consistent with the independent evidence that we saw at the inquest”.

The CCTV footage of Ngata has been suppressed since 2018.

The Ngata family viewed it under police supervision after his death, and it was used as evidence during the coronial inquest in 2022.

Police’s actions were first called into question in a Sunday investigation which found officers went against their own policy by fitting a spit hood incorrectly, leaving Ngata in a prone position, and failing to monitor him continuously.

That same year, the Independent Police Conduct Authority (IPCA) released a report stating that Ngata was likely unresponsive when he arrived at the cell, and that “police failed to fulfil their duty of care to Alo Ngata”.

Why was Alo Ngata arrested?

Alo Ngata restrained by police during his arrest in 2018.
Alo Ngata restrained by police during his arrest in 2018. (Source: Sunday / Supplied )

Alo Ngata was described by his family as a hardworking and loving man who adored his siblings and parents.

He had no history of violent offending but did struggle with bipolar disorder and substance abuse.

Those close to Ngata said in the lead-up to his arrest he was using methamphetamine and his behaviour had become increasingly erratic and unpredictable.

At about 3pm on July 1, 2018, Ngata had an argument with his girlfriend at her central Auckland flat. He ran outside screaming and swearing, then began to violently assault Mike Reilly who was walking past at the time.

He was extremely agitated and violent, kicking the 76-year-old unconscious.

Ngata then went to his car and got what appeared to be a wooden or metal bar and used it to hit his own head several times. There were also reports of Ngata headbutting the ground.

While Reilly survived the attack, he now lives with severe injuries.

In his report, Bates said Ngata’s methamphetamine use likely led to his psychotic state on that day.

Police had difficulty gaining control of Ngata at the scene. Tasers and pepper spray were deployed, restraints were applied to Ngata’s wrists and ankles, and a spit hood was fitted over his head.

The coroner found that due to his agitated state, “there can be no criticism of police actions at this stage”. The IPCA took the same view.

When did things go wrong?

Surrounded by his family, Alo Ngata’s life support was turned off three days after the incident.
Surrounded by his family, Alo Ngata’s life support was turned off three days after the incident. (Source: Supplied)

After his arrest, Ngata was transported in a police van to the Auckland Custody Unit.

Bates said he was “in the back of the van alone, lying prone on the floor”.

He noted the spit hood was left on and given Ngata’s face down position, “he could not have been well-monitored during transportation”.

The first opportunity custody staff had to assess Ngata’s well-being was upon his arrival at the custody unit, but the coroner said that was not done.

The police custody supervisor gave evidence that Ngata was “assaultive, muttering incoherent noises, and was difficult to deal with”.

However, the coroner said the CCTV footage gives the impression that Ngata was semi-conscious and unresponsive while being carried to his cell.

“Contrary to this impression, the officers carrying Alo report that he continued to struggle with them and was difficult to hold.”

Bates described CCTV showing Ngata being dropped and landing heavily, face-first on the floor.

He made no attempt to brace when he fell and had no obvious reaction to landing, leading Bates to conclude that Ngata was in a state of “severely reduced consciousness”.

“Police policy categorises this as a state of medical emergency requiring hospitalisation. Police did not recognise this.”

Six police officers spent about eight minutes in the cell with Ngata removing Taser prongs from this clothing. At no point did officers lift the spit hood to check his condition and he remained face down for most of this process.

The coroner noted that one officer thought they may have heard Ngata say, “I can’t breathe”, but other officers questioned about this did not recall hearing that comment.

The spit hood was left on, and Ngata was left lying prone when officers exited the cell.

Bates said Ngata “shouldn’t have been left in a prone position on the cell floor at the [Auckland Custody Unit], particularly without constant monitoring and with a spit hood fitted”.

Police anticipated Ngata would remove the spit hood himself once the handcuffs had been removed, but he did not move from the position he was left in, face down with his hands still behind his back.

An illustration of Alo Ngata after he was left face down in his cell with the spit hood still on.
An illustration of Alo Ngata after he was left face down in his cell with the spit hood still on. (Source: TVNZ)

About one minute and nine seconds later, an officer monitoring him via CCTV realised he had not moved and raised the alarm.

There was some delay in re-entering the cell and by the time officers fully re-entered, Ngata had been alone for three to four minutes.

When the spit hood was finally removed, a patch of blood could be seen in the hood in the region of his mouth and nose on CCTV footage.

Police discovered he had stopped breathing and CPR commenced.

IPCA chairman Judge Colin Doherty told TVNZ in 2020 that there was an “unacceptable delay” in resuscitation.

“His hands began to turn blue and that was observed by someone outside the unit monitoring on the television monitor,” Doherty said.

“Even then when they recognised something was up, it took them a minute or two to get in there… It is appalling.”

The police rejected any suggestion that the delay in re-entering the cell was unacceptable.

What is a spit hood?

A man wearing a spit hood.
A man wearing a spit hood. (Source: Online via manufacturer website)

A spit hood is an approved police restraint tool designed to stop prisoners from spitting and biting.

The use of the hoods is controversial. There have been calls to ban their useon vulnerable prisoners in New Zealand.

A correctly applied spit hood has the solid plasticised part covering the mouth, with the mesh above the bridge of the nose, and secured with a tie at the top of the head.

Witnesses supported police accounts that Ngata was spitting at officers at the scene of his arrest.

Police policy states that a person’s face is not to be covered after pepper spray has been used.

Bates said that due to Ngata being pepper sprayed and bleeding from his mouth and nose at the time of his arrest, he had “no difficulty finding that the spit hood would have restricted Alo’s breathing”.

He considered it most likely the spit hood was initially applied correctly but moved into an incorrect position during the time he was being transported in the van.

“It was far too high by the time he was taken from the van, with the solid plasticised part covering his entire face, including his eyes,” Bates said.

Graphic illustration of the incorrect position of spithood on Alo Ngata’s head.
Graphic illustration of the incorrect position of spithood on Alo Ngata’s head. (Source: TVNZ)

“From the moment Alo was removed from the van, officers failed to recognise the spit hood was positioned too high and had the potential to restrict his breathing.

“The incorrectly positioned spit hood that had been left in place not only added to the risk of positional asphyxia, but it also meant officers could not see Alo’s face, making monitoring of him far more difficult.”

However, in his finding, Bates was emphatic that it was impossible to quantify the contribution of the spit hood to Ngata’s death and whether the outcome would have been different if it had not been used.

“To what extent, if any, the spit hood contributed to Alo’s death cannot be quantified. Suffocation remains a possible contributing factor, but no more than a possibility,” he said.

“However, earlier removal of the spit hood would have permitted more effective monitoring.”

The coroner concluded that police training on the use of spit hoods had been inadequate. Police said spit hood training is under review.

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