The death of a heroin addict in a Dunedin police station cell was not the fault of officers involved with her detention, but their behaviour amounted to a neglect of duty, the Independent Police Conduct Authority says.
Juanita Shaw, 36, was found dead from an overdose at the Dunedin central police station in August 2007.
During and after her arrest, officers had not checked her record for alerts indicating she had suicidal tendencies.
The report says their assessment failed to establish she needed the highest level of care and monitoring so they did not realise a doctor was needed.
The officers did note she was agitated and arranged for her to take her prescribed daily dose of methadone, used to treat heroin addiction.
Ms Shaw was found dead shortly afterwards. The coroner concluded she had probably also taken methadone before her arrest.