A police officer who broke a detainee's ankle was found to have used excessive force.
The woman was being held overnight after breaching bail conditions, but ran away from a trio of officers who entered her cell.
The woman told the Independent Police Conduct Authority (IPCA) that she heard a snap when one of the officers forced her to the ground. For the rest of the night, she complained of a broken ankle.
The officer who caused the injury claimed she had injured herself by kicking the cell door, though the IPCA confirmed this was not the case.
The authority also found that the woman wasn't trying to escape the custody unit, and had no means to do so.
When the officer called an on-duty doctor, they reportedly told him to "give her some Panadol".
It was not until the next morning, when another group of officers started their shifts, that the severity of her injury was assessed.
She was rushed to hospital by ambulance, where she received surgery for two broken bones, the IPCA said.
The authority said the officer who caused the injury was not the only one at fault, writing in its report that the incident could reflect a "wider systemic problem" with the Custody Unit.
"This was not a single error made by one person," it says. "It took a team of people to fail to provide [her] with the care she was so clearly needing."
Police staff repeatedly misgendered the trans woman in their reports, using her deadname (name before transitioning) and male pronouns, the IPCA noted.
This raised concerns about the officers' attitudes toward the woman and could indicate cultural issues within the unit, the authority said.
Police acknowledged the review and said the officers "fell short" of its standards.