Warning: this story contains themes involving suicide and self-harm
A brain-damaged man suspected to have killed himself while in a secure mental health unit should not have been there, and was being treated in a way that did not help his condition, a report into his death says.
His foster parents say the report is not strong enough to lead to change at the unit.
Tamaki Heke, 24, was found dead in Waitematā DHB's He Puna Wāiora unit in May 2019. His death came one week after another suspected suicide there.
Heke had previously been diagnosed with foetal alcohol spectrum disorder. He had an intellectual age between nine and 12 years old, and was consequently prone to copycat behaviour.
Heke also suffered from post-traumatic stress disorder, attention deficit disorder and intermittent psychosis. He had been admitted to the acute mental health unit 11 times because of suicidal thoughts and self-harm.
His final stay was five months.
On the night of his death, Heke's foster parents warned He Puna Wāiora he was suicidal and asked for him to be watched closely.
"He Puna Wāiora operated models of care that were unhelpful to meeting Tamaki's needs," Waitematā DHB's investigation into the 24-year-old's death found.
"A model akin to those used in intellectual disability services would be more effective, with a stable group of carers and an intensive structured support approach.
"The criteria to access intellectual disability services is tight, so people with foetal alcohol spectrum disorder are often unable to access appropriate services, and they only reach the threshold for mental health services in times of crisis, when compulsory treatment is needed to manage acute risk.
"There was no immediate indication that Tamaki was contemplating suicide. In view of his large meal, happy demeanour, and a request to charge his phone shortly before his death. And it's unlikely a particular action could have prevented Tamaki's death, which appears to have been impulsive," the report said.
Heke's foster parents Rita and Peter Wilcox told Checkpoint they would have liked to see stronger wording in the report and hoped change happened at He Puna Wāiora.
"There's some important stuff in there that the health system needs to learn from, and the worry would be they don't learn from it," Mr Wilcox said.
"Like Peter, I don't think it's strong enough," Mrs Wilcox said.
"There's so many reports that have come out and they agree … they need to make changes, and nothing happens. Years later they're still doing the same thing.
"That's my worry with the report, it's just glossing over that there is blame at Waitematā and they need to do something."
The care Tamaki got at He Puna Wāiora was not fit for purpose at all, Mrs Wilcox said.
"He was put on medication to treat what they thought were conditions, when really it was just his disability. He had brain damage from having foetal alcohol effects, and they were trying to medicate that, instead of giving him the emotional support he needed for day to day living.
"He needed somebody to guide him through life, and they were using medication to dope him up so that he didn't have to respond to life," she said.
"Basically if you look at the model they were trying to put on him, it was beyond his abilities in terms of his disability," Mr Wilcox told Checkpoint.
"That's probably one of the very strong points that needs to be made, is that when things aren't working then you need to actually stop and go, 'this isn't working, what do we need to do?'
"Instead they just kept on trying to repeat the same thing over and over again. It's institutional insanity."
The reason Tamaki ended up in a mental health unit was his IQ was too high to be meet the criteria for disability services help.
"He didn't qualify because he was maybe five points too high, but the assessments don't take into account all the other problems," Mrs Wilcox said.
"He had a very, very low function ability. That's where he operated - about a nine-year-old.
"Because the assessment doesn't take those two criteria into account, it only takes the intellectual, he didn't qualify for a thing. He didn't have a physical disability, to them he didn't have an intellectual disability because he was a few points too high, and they didn't take his function ability into account, because they don't do that in New Zealand."
When Tamaki was 18, he was kept in the mental health unit at North Shore for two weeks.
"Then they pushed him out into community because basically they said, 'there's nothing we can do for you, you don't qualify for anything'," Mr Wilcox said.
"At the same time we were asking for support and they said, basically, there's nothing.
"Ultimately, he ended up in prison, while he was on remand. For somebody [mentally] nine-to-12-years-old - that, I believe, is an absolutely appalling statement on our society."
"Some of the things that actually occurred to him through the system, if you looked at them through his eyes, you would regard as psychological abuse," Mr Wilcox told Checkpoint.
"He was in the community, in a place that he was enjoying, he was doing really well. His whole mood was great. They called him in one day to North Shore Hospital to have a routine follow through by the mental health team and he was told 'you're not going back'.
"Just like that, without any preparation. Nothing, just a cold, blunt 'you're not going back'."
The funding to support Tamaki's residential support with Piri Pono had run out, Mrs Wilcox said.
"So we weren't told to support him. His support workers from a separate agency who understood his condition weren't told, so there was nobody to support him. He was just picked up, taken and never went back. From that day on, he gave up."
Recognising adaptive function disability needs to happen, Mr Wilcox said.
"Adaptive function looks at an individual's ability to function independently in the community. Tamaki was unable to act and function independently in the community.
"I think that we have many like Tamaki being dumped in our community, struggling, turning up in all sorts of places where there shouldn't, causing problems. And that's purely because the health system fails to recognise adaptive function as a disability."
Tamaki's foster parents believe more disabled people's lives are at risk in the mental health system.
"We're very concerned about what is happening in our mental health system, and there are other people we talk to that express exactly the same concerns, that the system, like in Tamaki's case, when you talk to them, they ignore what you have to say. They don't want to look at it through the patient's eyes or through the family's eyes."
In a statement, Waitematā DHB said it continued to extend its condolences and thoughts to Heke's family, whānau and friends.
"Mr Heke's death was a tragic event and we fully understand the devastating impact this has had on his loved ones.
"Our mental health team cared for Mr Heke and worked with family over an extended period. Mr Heke's death was fully investigated by an expert panel, members of which were all external to and independent of the DHB.
"A priority amongst these is the need for the development of services better able to meet the needs of people with fetal alcohol spectrum disorder (FASD).
"The DHB fully accepts and agrees with this as an area for attention, locally and nationally.
"Waitematā DHB has raised the need for care and dedicated services for people with FASD with the Ministry of Health.
"The DHB offered to meet with the Willcox family to discuss the report but due to the Covid-19 lock down, this was not possible.
"There is an open invitation to meet with the family at a time that suits them."
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
Lifeline: 0800 543 354 or text HELP to 4357
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email firstname.lastname@example.org
What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.