Dad’s anguish at system failures
Uni student who died of suspected suicide at hospital ‘wasn’t bad enough’ to receive help, inquest hears
Jeremy Wilkinson This story deals with suicide and may be distressing for some people
The father of a university student who died of a suspected suicide says his daughter “wasn’t bad enough” to receive mental health support.
“I suppose she wasn’t doing illegal drugs, not an alcoholic, was young, pretty, going to uni, functioning, therefore couldn’t be that bad,” Owen Hume said yesterday at a coronial inquest into his daughter’s death.
Erica Hume died of a suspected suicide at Palmerston North’s infamous mental health ward “Ward 21” nearly eight years ago. Her death came just a month after that of 30-year-old Shaun Gray in the same ward.
The 21-year-old Massey student and Gray were friends and she indicated to a care worker that Gray’s death was a factor in her mental health deteriorating before she was admitted to the hospital.
Last month a coronial inquest into Gray’s death was carried out and multiple issues about the way the hospital handled his care were raised.
In both Gray and Hume’s cases their care workers deemed them to be high risk when they were admitted to the ward, however staff on the ward failed to fill out admission forms.
“It has taken us eight years to get here, a long and frustrating eight years,” Owen Hume said at the Palmerston North District Court yesterday.
“I hope that not only the coroner but all of you get an understanding of what happens when something isn’t dealt with early by trained intuitive people and what happens when family are excluded from the process.”
“From the beginning, it was not just one part of the mental health system that failed Erica, it was just about all of it.”
According to the summary of facts, on May 7, 2014, Erica called her care worker at Palmerston North Mental Health Services and said she was having thoughts about harming herself.
The next day she was admitted to Ward 21 on a voluntary basis and her care worker filled out a risk assessment form classifying her as “high risk”.
However, staff at the ward left her admission paperwork for the night shift to complete and no formal assessment of her risk was undertaken while she was in the ward’s care.
Overnight she was checked every half hour. The next day she briefly left her room for lunch before returning again.
Just before 1pm she was found unconscious inside her room and could not be resuscitated by the staff.
She was taken to intensive care but died over a week later.
While she was still in ICU her family went to the ward to get answers about what had happened.
They were horrified to find out that weeks earlier Gray had killed himself in a similar manner to the way Erica had attempted.
“She would have been devastated by that news,” her father said.
He remembers his wife, Carey, telling the manager at the ward that she had “murdered my daughter”.
“I recall saying to her, “You’ve got one f**ked up system here.”
Failure at every step
Owen Hume told the court his daughter’s mental health journey started years earlier when she was in Year 12 when she divulged to a teacher that she “wasn’t doing too good”.
The teacher referred her to the school counsellor who had no mental health training and less than two years’ experience.
That counsellor took Erica to a doctor who prescribed her antipsychotic medication.
Meanwhile, she developed multiple eating disorders.
All of this occurred without her parent’s knowledge.
Owen Hume said his daughter was poorly monitored and her eating disorders developed into other coping mechanisms such as cutting.
Her diary indicated that she wanted to tell her parents what was happening but didn’t know how.
“Where was the professional help to make this happen?” Owen Hume said.
By the time they found out, and the Bay of Plenty District Health Board became involved at the recommendation of the counsellor, it was too late for her to access youth mental health services.
That DHB also found that selfharming didn’t start until after contact with that counsellor and the medication prescribed to her could have been the cause of some of her problems.
After finishing school she planned to attend Massey University back home in Palmerston North and her parents sought to get her access to mental health support.
However, she was deemed “not bad enough” to access Palmerston North Mental Health Services and was recommended to access the university’s counselling services.
There were only three appointments available to students so she tried to save these until she was really bad and tried to cope by herself.
Massey quickly established that Erica’s situation was too serious for them to deal with and referred her back to Palmerston North Mental Health Services.
After her death, her parents pushed for a review into Erica’s healthcare at Ward 21 which they felt had poor communication, culture, overworked staff, below-standard facility and a District Health Board more interested in damage control than truth.
“Erica did not want to die, she wanted to live and she asked for help,” Owen Hume said.
“The purpose of this inquest is to answer why she did not get that help [and] ultimately paid the price with her life.”
Scope of the inquest
There are a total of 64 specific issues or questions that Coroner Matthew Bates is looking into over the course of the inquest.
Among those issues are the admission and handover procedures for staff at the ward, the medication Erica was prescribed, the physical environment, how she was supervised at the ward, and staff training.
Many of these same issues were explored at Shaun Gray’s inquest last month and some of them were identified in May last year when Chief Ombudsman Peter Boshier paid a surprise visit to the infamous ward and released a report describing it as one of the worst in the country.
Erica Hume’s care worker at Palmerston North Mental Health Services — who has name suppression — was the first witness called before the inquest and told the court she recommended Erica be admitted to Ward 21.
“I thought the risk was going up.” she said.
after Erica came to her in distress on May 4, 2014.
The nurse filled out a risk assessment that noted that Erica was at a high risk of self-harm before being admitted to the ward the next day.
Staff at the ward did not complete their own assessment and admission forms were left for the staff on nightshift to complete.
The hearing is set down for several weeks, with nearly 30 witnesses due to be called.