Nicky Stevens’ death ‘avoidable’
‘‘Our family warned responsible DHB staff on several occasions, including in writing, that Nicky was at high risk of suicide, and should not be allowed out of his secure ward without supervision. ‘‘The DHB chose to ignore our warnings about the risk to N
The death of a Hamilton man who took his own life after walking out of a mental health facility could have been avoided had mental health services listened to warnings from his parents, a coroner has found. Nicholas Taiaroa Macpherson Stevens’ parents Jane Stevens and Dave Macpherson are now demanding an apology from the Waikato District Health Board following the damning report which shows a litany of red flags in his treatment and response. The 21-year-old’s body was found in the Waikato River three days after he went missing from the Henry Rongomau Bennett Centre (HBC) at Waikato Hospital in 2015.
In a report released on Thursday following an inquest in the High Court in Hamilton in June, Coroner Wallace Bain ruled that Nicky’s death was avoidable.
‘‘The circumstances of Stevens’ death make it clear that our mental health system is in urgent need of being overhauled,’’ Coroner Bain said.
Nicky Stevens was a free-spirit. A young man who loved the environment, was creative and took refuge in music.
He was also dealing with schizophrenia and had a long history of mental illness and self harm that saw him put under a compulsory care order at HBC in February 2015.
At the time Nicky was believed to be suffering a relapse of psychosis, probably schizophrenia and increased risk to self, the report states.
On Monday, March 9 he left HBC on unescorted leave as part of a group of smokers following lunch.
CCTV footage shows he returned to the facility twice before disappearing down the gully. He never returned.
A passer-by found his body in the Waikato River three days later, on March 12.
Nicky’s death sparked multiple investigations – one critical of the police response to a missing person report in the days following his disappearance.
In his findings Coroner Bain stated there were ‘‘deficiencies in care’’ provided to Nicky that if not present could have reduced his personal risk.
‘‘Mr Stevens was a very ill young man with significant mental issues.
‘‘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.’’
Details in the coronial report show that between February and his disappearance on March 9 doctors met with Nicky’s family who aired concerns over him being allowed unescorted leave. Nicky was psychotic, hallucinating and saying he ‘‘wanted to be on the other side’’. Within weeks of being admitted he was assessed as being able to take unescorted leave, the report said.
Medical staff were aware of a previous visit to the Waikato River and contemplation of suicide during an unescorted leave in February.
Clinical notes showed the day before Nicky disappeared his mother Jane Stevens was vocal in her concern about how Nicky was behaving on leave.
Nicky was allowed to have 15 minutes of unescorted leave twice a day – a directive ‘‘loosely interpreted’’, the report said. His late return the day before he disappeared was not raised at a treatment plan meeting the next day.
Granting him unescorted leave was ‘‘unreasonable and unnecessary risk’’, the Coroner said.
‘‘The treatment Nicholas received was well short of what he and his parents would have expected. As as result of deficiencies in his care, he was able to take his own life in the precise manner and place that he had previously said he would.’’
Several errors in raising the alarm were found including the failure of a fax sent by a nurse at HBC to police informing them Nicky was missing to transmit for 12 hours, delaying a search. Nicky’s parents and brother Tony Stevens said the report showed the DHB had failed to ensure Nicky’s safety.
Dave Macpherson and Jane Stevens want an apology from the Waikato DHB which they say failed to provide adequate care to son Nicky Stevens.