But an Independent Police Conduct Authority (IPCA) report released today found that there were police failings in the care of Lam.
After members of the public had overpowered Lam at the dairy, he was arrested, telling officers “he was trying to reach heaven”.
Police responding to the New Windsor dairy attack in 2023. Photo / Hayden Woodward
Lam was acting aggressively and erratically and tripped, falling to the ground while attempting to escape, the IPCA report said.
Given his behaviour, the officers were unable to determine whether he had any injuries.
The IPCA found there was no indication he needed urgent hospital attention and that it was appropriate to take him to the Auckland Cusody Unit (ACU), where he could then be medically assessed.
Upon arrival at the ACU, Lam got out of the patrol car and attempted to flee.
Four officers brought him under control and escorted him toward the designated search area.
One of the officers tripped Lam “unnecessarily”, the IPCA report said, causing him to fall to his knees.
The IPCA report said officers claimed Lam’s behaviour was heightened, he seemed very strong and they believed he was under the influence of drugs.
Three officers held the man in a standing position against a wall in the search area. One of the officers held him by the hair then pulled him off balance and lowered him to a prone position on the floor.
The IPCA accepted that while Lam was “generally behaving erratically”, footage indicated he was not offering any significant resistance while being held against the wall.
They found it was “unnecessary” for the officer to hold Lam by the hair and take him to the ground at this point.
The police sergeant in charge of the ACU thought the man was suffering some kind of psychosis or “excited delirium” and believed he posed a risk to staff.
It was decided that it was necessary for Lam to be placed into a restraint chair – a decision found to be justified by the IPCA.
However, the IPCA found it was unreasonable for Lam to have remained handcuffed while in the restraint chair.
Once in the chair, a custody officer completed an evaluation of Lam’s physical and mental health, as required when detainees are brought into custody units.
The IPCA said this was primarily treated as a procedural step rather than a considered assessment of risks and welfare concerns, and there was other relevant information that could have been included.
While the man was monitored in the restraint chair, the sergeant phoned the police doctor, who advised that if the man were experiencing “excited delirium”, he would need to be taken to hospital, and an ambulance was called.
A custody officer then became concerned that Lam was quickly deteriorating, so the ambulance was called again and asked to attend immediately.
At about 12.40pm, ambulance officers took Lam to hospital under sedation.
At around 5pm, Lam was discharged from hospital and returned to the ACU. Hospital discharge papers noted that he was presenting well and did not appear to be at increased risk of harm to himself or others.
The sergeant in charge of the night shift observed that Lam was not talking, was very unsteady on his feet and needed assistance to walk.
He was aware Lam had been sedated and assessed him as being extremely intoxicated.
The sergeant arranged for Lam to be further assessed by the police doctor and by a mental health doctor – a decision accepted in the ICPA report.
The police doctor advised that Lam could be placed on “frequent” monitoring, requiring him to be checked five times an hour, rather than being constantly monitored.
The IPCA said given the advice of the health professional, it would not be fair to criticise the sergeant’s decision to downgrade the monitoring regime.
Over the course of the night, custody staff recorded that they completed 80 checks on Lam.
More than half of these checks do not appear to have been conducted in line with police policy, as officers observed Lam on the CCTV screen, rather than physically going to the cell, the IPCA said.
The custody team, who had dealt with Lam the previous day, returned in the morning and were told there had been no issues with him overnight.
At about 7.30am, Lam removed his overalls, mostly keeping a blanket wrapped around himself.
The IPCA accepted that occasionally, detainees choose not to wear clothing while in the cells.
However, they said Lam removing his clothing should have prompted some concern about the reasoning.
Throughout the morning, custody staff recorded that they completed 30 checks on Lam.
Some of these checks involved talking to him over the intercom inside his cell, looking at the CCTV screen, or officers checking on him from their workstations.
The IPCA found these checks were inconsistent with policy as the officer did not go to the cell.
At about 10.54am, an officer went to check on Lam and found him unresponsive.
Officers promptly commenced first aid and Lam was taken to Auckland Hospital and died three days later, as a result of self-harm.
The ICPA said after reviewing footage, it was apparent that Lam was listening for, and observing staff movements and “looking for an opportunity to self-harm”.
It said that while it couldn’t confirm the accident could have been prevented, proper checks would have reduced the opportunity for it to occur.
The IPCA extended condolences to Lam’s family and friends.
Auckland City District Commander, Superintendent Sunny Patel, said the police acknowledged the IPCA’s findings.
“A critical incident investigation was commenced as well as a review into the prisoner checking system,” Patel said.
“As a result, police have implemented several learnings, including updating the national People in Police Custody Policy.
“We would also like to again extend our condolences to the man’s family and friends.”
The matter remains with the coroner.