❚ The Coroner made several recommendations in his findings including the Waikato DHB review its consultation policies and include steps to minimise differences between statutory duties and family expectations in care and treatment.
❚ He urged the Waikato DHB review its escorted leave policy, saying leave allocations for patients should be more closely monitored and those allowing patients to leave a closed ward should be able to quickly establish if they returned.
❚ Feedback from family and friends on how a patient behaves on leave should be assessed when they return and incorporated into a treatment plan.
❚ Nicky was a smoker and since the DHB’s policy was to be smoke-free he had to leave premises to have a cigarette.
❚ Although the Coroner applauded the smoke-free policy, he recommended that consideration be given to at risk patients to smoke in a safe environment.
❚ Smokefree rooms with mechanical ventilation should be provided where patients are under compulsory care allowed for under the Smokefree Act, he recommended.
❚ In a letter family said the DHB was responsible for Nicky’s death and ‘‘has made no effort to support the family since that time’’.
❚ The DHB funded only minor counselling support for family, they said, despite extensive legal bills to front a coronial inquest.
❚ Coroner Bain also agreed there was a need for an independently funded whanau advocacy service to help provide families with legal aid representation. Findings from the report have been forwarded for review as part of an inquiry into the country’s mental health system.
❚ ‘‘It is hoped that the major overhaul of the mental health system will go a long way to meeting the concerns that Nicholas Stevens’ parents have raised,’’ Coroner Bain said.