Coroner blasts DHB over death
Family demand apology after damning ruling on son’s suicide at care facility
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.