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

Waikato Times - - News - Phillipa Yalden [email protected]

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.

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