Vital warning signs ignored and son died: Family
Foster mum warned staff Tamaki Heke was at risk but he was dead within hours
Agrieving foster father says staff ignored crucial warning signs before his son’s suspected suicide at an acute mental-health unit just days after another sudden death.
And though a report has cleared clinicians of blame, Peter Willcox feels it is an attempt to absolve Waitemata¯ District Health Board of responsibility.
Willcox’s worried wife, Rita, phoned staff at North Shore Hospital’s He Puna Waiora clinic in May last year, warning Tamaki Heke was suicidal, but was assured he was getting good care. Hours later the family were told the 24-year-old had been found dead in his room.
His suspected suicide came four days after a fellow patient at the unit also died suddenly. The deaths are subject to Coronial investigations as well as an independent high-level review.
The DHB says it understands the devastating impacts on Heke’s loved ones and has extended an open invitation to meet and discuss the report’s findings. It says the death was fully investigated by an independent expert panel.
Heke’s foster family want a mentalhealth system overhaul and complained to the Health and Disability Commissioner about the care received.
The Herald has obtained a copy of the DHB’s internal investigation report, which the organisation declined to release. It sheds light on events leading up to the tragedy and Heke’s complicated background, which included being diagnosed with fetal alcohol spectrum disorder (FASD) and a long history of self-harm and suicide attempts.
Despite his foster mother’s warning and Heke previously trying to end his life at the unit, the report found his “attempt to die was impulsive and taken without thought for the consequences”.
“It is unlikely that a particular action could have prevented TH’s death. However, addressing the whole system improvement issues may prevent a death in these circumstances from happening again.”
Willcox believes staff missed obvious warning signs and ignored the family’s pleas to watch over their son.
“Effectively he was stuck in a prison for three years with nothing whatsoever to stimulate him or do.
“It’s no wonder that Tamaki was spiralling down.
“Staff are not listening to family members, to people who know these individuals the best. The system’s not learning from its mistakes. It just keeps on repeating them.”
The report describes Heke as “personable and warm”, talented and creative. He taught himself to play piano by studying YouTube videos and developed skill in carving.
Days before the death, the Willcox family warned staff Heke was distressed by the other patient’s suspected suicide and at high risk. They requested he be kept in ICU for his safety. The request was declined and he was moved back to the open ward, though the family wasn’t told.
Heke had been an inpatient at the unit for about five months at the time and was considered “like family” by staff. He’d returned to the facility about 6pm that day after being granted leave with his foster parents.
The Weekend Herald reported last year that soon after arriving back, Heke called his family, “indicating what he wanted for his funeral”.
His foster mother immediately rang unit staff to warn them, asking for him to be placed on watch.
“She was concerned for his safety and was given reassurance that he was receiving good care,” the report states.
“Although TH was ruminating on the recent suicide in the unit and his recent relationship break-up, TH remarked to staff that he ‘won’t do anything tonight’. The clinical notes reflect that staff were aware of these two stressors.”
After a meal of fish and chips, Heke remained in his room with the door unlocked on hourly therapeutic observations. He was last seen alive at 9.05pm and found unresponsive at 9.40pm. Staff activated an emergency response and tried to resuscitate him for 25 minutes before he was pronounced dead.
His foster parents were informed by phone at 10.35pm.
“They were phoned again at 11pm and asked if they wanted to come and see TH before he was transported for autopsy. They declined. The family have expressed upset at this procedure and felt that the police should have been sent to their home with someone from Victim Support.”
The review team investigated Heke’s background. It found he frequently talked of suicide, on some occasions telling a nurse “I’m always suicidal”.
“Staff were therefore tasked with not simply assessing the presence or absence of suicidal thoughts, but their intensity and TH’s intent to act on those thoughts.”
Though staff were aware of Heke’s feeling about the recent patient death, “there was no acute concern of increased suicidality”.
The report also noted a tension between unit staff and Heke’s foster family, who believed his FASD disability had been misunderstood by clinicians.
The report found clinicians could not have prevented Heke’s death, but identified “system improvements”, in particular around gaps in care for patients with FASD. It also stressed the importance of family connections to supporting patients, saying clinicians should view families with compassion and understanding.
Heke was one of four mentalhealth patients to die while under compulsory care at Waitemata¯ DHB in two years. Waitemata¯ DHB Specialist Mental Health and Addiction Services clinical director Murray Patton said the DHB extended its condolences and thoughts to Heke’s family, whanau and friends.
The mental health team had worked with Heke and his family over an extended period. His death was fully investigated by an expert panel, independent of the DHB.
“The panel did find a number of contextual factors that have contributed to recommendations for further action. A priority amongst these is the need for the development of services better able to meet the needs of people with fetal alcohol spectrum disorder. The DHB fully accepts and agrees with this as an area for attention, locally and nationally.”
Waitemata¯ DHB has raised the need for care and dedicated services for people with FASD with the Ministry of Health. In the absence of these specialised services, DHB treatment plans for people with FASD are tailored to individual needs from within a range of mental health, community and/or disability support services.
“The DHB offered to meet with the Willcox family to discuss the report but due to the Covid-19 lockdown, this was not possible. There is an open invitation to meet with the family at a time that suits them.”
Willcox said his family, who had cared for Heke since the age of 1, still grieved, trying to make sense of what occurred.