The mother of a man who drowned after leaving the mental health unit at Waikato Hospital unsupervised says concerns for his wellbeing were constantly ignored by hospital staff.
The inquest has opened on Wednesday in Hamilton for 21-year old Nicholas Taiaroa Stevens, who was known as Nicky.
He walked out of the Waikato DHB's mental health unit - the Henry Rongomau Bennett Centre - unsupervised in March 2015. His body was found four days later in the Waikato River.
Described as a philosopher, environmentalist, musician, artist and free-spirit, Nicky Stevens first came under the wing of community mental health services in his teens.
He was diagnosed with disorganised schizophrenia.
His mother, Jane Stevens gave evidence on the opening day and said her son's condition was characterised by incoherent thoughts and behaviour.
At 19, after a psychotic episode described by Jane as "terrifying", Nicky was admitted to the centre for the first of three times after slashing his wrists.
Mr Stevens was granted unescorted leave from the hospital grounds for 15 minutes at a time, primarily for a cigarette break.
"We were fearful about him being out on his own, and we wanted his leave to be supervised," Ms Stevens said.
"Our fears for our son were realised when he went missing on an unescorted break and was found dead in the Waikato River in March 2015."
Ms Stevens said her son's death was preventable.
"Our son suffered from a serious mental health illness but it shouldn't have been a death sentence."
Ms Stevens told the Coroner that the whānau was not informed for three days that Nicky had slashed his wrists and was in hospital.
Nicky told her how he had also tried to drown himself, she said.
"It is clear to me now that my requests (to the hospital) were not taken seriously."
She said even though clinical records showed Nicky had told her about trying to drown himself they appeared not to have believed him or not seen it as important enough to investigate.
Ms Stevens said her son was good at hiding his condition from medical staff, so it was important the family were listened to, but that did not happen.
"If Nicky said he was not suicidal, they seemed to accept his word and they just didn't seem to look any deeper."
In the days leading up to his disappearance, Nicky's behaviour got worse and his family feared that he was in immediate danger.
"Mentally and physically fighting aliens, expressing the belief he had another life in the spirit world where he had superpowers and could battle the aliens, which were going to kill him and his friends and whānau," Ms Stevens said.
Mr Stevens had also asked his friends to kill him.
"He made it clear to whānau and friends that there was no other option but to die."
On the day Nicky Stevens disappeared, he walked out of the centre and headed off down a track to the Waikato River.
She said CCTV footage of her son just before he left the hospital for the last time was very distressing to watch.
The footage showed Mr Stevens sitting on the floor, arms around his torso and swinging backwards and forwards.
"Obviously in distress and at least one confirmed staff member walked past and ignored him," Ms Stevens said.
"It breaks my heart to think how invisible and unimportant he must have felt and had just one person had intervened, Nicky could still be with us today."
Ms Stevens said she hoped the Coroner's findings and the current inquiry into mental health will make a difference for others in the same position as Nicky and his whanau.
"This is a unique opportunity to give meaning to Nicky's life and death by producing outcomes that contribute to change."
The inquest before Dr Wallace Bain continues through until Friday, with one of the psychiatrists who treated Mr Stevens giving evidence on Thursday.
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