Coro­ner blasts DHB over death

Fam­ily de­mand apol­ogy after damn­ing rul­ing on son’s sui­cide at care fa­cil­ity

The New Zealand Herald - - Front Page - Natalie Akoorie

The griev­ing fam­ily of a young man who died while un­der the care of Waikato District Health Board are de­mand­ing an apol­ogy after the re­lease of a damn­ing coro­ner’s find­ing.

Nicky Stevens’ death was avoid­able, the coro­ner ruled in the re­port re­leased to the Her­ald yes­ter­day.

It’s vin­di­ca­tion for his par­ents Dave Macpher­son and Jane Stevens who say they still want the apol­ogy they have been wait­ing al­most four years for, since their youngest child took his life in early 2015.

Macpher­son and Stevens also want an apol­ogy from the Min­is­ter of Health David Clark for all the fam­i­lies whose loved ones died by sui­cide while in the care of a men­tal health fa­cil­ity, and will con­sider mak­ing a re­quest for com­pen­sa­tion.

Coro­ner Dr Wal­lace Bain found Ni­cholas Ta­iaroa Macpher­son Stevens’ death was self-in­flicted after the 21-year-old was al­lowed out of the Henry Ron­go­mau Ben­nett Cen­tre at Waikato Hospi­tal on March 9, 2015 on un­escorted leave, against the ex­press di­rec­tion of his par­ents.

In his re­port, Coro­ner Bain said Stevens’ death could have been avoided had the ad­vice of his par­ents not to al­low their son on un­escorted leave been ad­hered to.

“Mr Stevens was a very ill young man with sig­nif­i­cant men­tal is­sues,” the coro­ner said.

“The med­i­cal staff had heard ex­ten­sively from his par­ents of his be­hav­iour and what he said he was go­ing to do. His par­ents op­posed un­escorted leave as they feared he would do ex­actly what he ul­ti­mately did,” he wrote.

“. . . The treat­ment Ni­cholas re­ceived was well short of what he and his par­ents would have ex­pected. As a re­sult of the de­fi­cien­cies in his care, he took his own life in the pre­cise man­ner and place [he had said] he would.”

The coro­ner agreed with ex­pert opin­ion that the de­ci­sion by the psy­chi­a­trist re­spon­si­ble for Stevens’ care to al­low un­escorted leave was un­sound and could not be jus­ti­fied.

A num­ber of er­rors in rais­ing

the alarm with po­lice in­cluded that a fax re­port­ing him as a miss­ing per­son did not trans­mit for al­most 12 hours. It was two days be­fore po­lice be­gan search­ing.

The coro­ner’s rec­om­men­da­tions in­cluded that:

● Leave should be more closely mon­i­tored and there should be a mech­a­nism to quickly es­tab­lish whether a pa­tient has re­turned;

● Waikato DHB im­ple­ment a sys­tem to re­view es­corted leave and how a pa­tient re­sponds to it;

● The DHB re­view its con­sul­ta­tion poli­cies and in­clude steps to min­imise dif­fer­ences be­tween pol­icy and fam­ily ex­pec­ta­tions;

● All district health boards con­sider a se­cure smok­ing area for men­tal health pa­tients be­cause of na­tional smoke­free cam­pus poli­cies.

Coro­ner Bain di­rected that sub­mis­sions from Stevens’ wha¯nau, in­clud­ing older brother Tony, be con­sid­ered by the Gov­ern­ment In­quiry into Men­tal Health and Ad­dic­tion which re­ported back this week.

They in­cluded an ur­gent need for an in­de­pen­dent body to in­ves­ti­gate com­plaints and an in­de­pen­dently-funded wha¯nau ad­vo­cacy ser­vice to help fam­i­lies make sub­mis­sions like the ones made by Stevens’ fam­ily for his coro­nial in­quest. Stevens and Macpher­son told the Her­ald their son died as the re­sult of mis­takes and they wanted an “un­qual­i­fied apol­ogy” from the DHB, of which Macpher­son is now an elected of­fi­cial.

They said the DHB must “make good” all the missed chances to sup­port the fam­ily fol­low­ing the tragedy.

In a state­ment, DHB in­terim chief ex­ec­u­tive Derek Wright called Stevens’ death a ter­ri­ble tragedy. He ex­pressed his sin­cere sym­pa­thy to the fam­ily for their loss but stopped short of apol­o­gis­ing.

Pressed on the apol­ogy, a spokes­woman later said the DHB would read the coro­ner’s find­ing be­fore de­cid­ing whether to add to the state­ment.

Wright said since Stevens’ death the DHB had made a se­ries of changes in­clud­ing a stronger em­pha­sis on wha¯nau in­volve­ment, stricter rules around leave and more staff.

Photo / Alan Gib­son

Jane Stevens with a photo of Nicky, who took his own life while on un­escorted leave which his fam­ily had op­posed.

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