The father of a young man who drowned after walking out of the mental health unit at Waikato Hospital unsupervised says his care was a train wreck waiting to happen.
Dave Macpherson. Photo: RNZ / Andrew McRae
Nicky Stevens, who was 21 and suffered from schizophrenia, died in Waikato River in March 2015.
His inquest ended in Hamilton today.
Nicky's father Dave Macpherson told the inquest the family had been closely involved in the various stages of his son's care and they thought he was in the best place to receive treatment.
However, Mr Macpherson said sadly the family's experience with Waikato DHB's mental health services removed all trust they once had in the system.
He told the Coroner that the granting of unescorted leave placed his son in danger, especially as he had tried to kill himself at least once.
Mr Macpherson said clinicians ignored the family's request for only escorted leave breaks.
"The hospital has an absolute duty to care to see that he does not come to any harm."
Nicky Stevens was at a mental health facility and was considered a suicide risk, but was allowed to take an unsupervised cigarette break. Photo: Givealittle
Red flags about care at the hospital were raised when his son had earlier tried to take his own life, he said.
The family only found out three days later that Nicky had been admitted to the emergency department after a suicide attempt.
Mr Macpherson told the Coroner the family went to the police to lay a complaint because they felt the DHB had handled his son's care and disappearance badly.
Police considered provisions in the Crimes Act around culpable homicide but did not pursue it further.
Mr Macpherson said they only ever wanted the DHB held responsible, not any individual clinicians.
"We were very unhappy about some of the decisions by individual staff members, they had been badly wrong, but more importantly we felt it was a DHB responsibility."
Nicky Stevens' lead carer in the days leading up to his death told the inquest Mr Stevens had told staff he did not want his parents involved in discussions around his care.
Nicky's mother Jane Stevens, who was back in the witness box on Friday, disputed this.
She said while Nicky, after trying to kill himself, had told emergency department staff that he wanted to tell his parents first about what happened, at no other stage did he want them excluded from decisions around his care.
Jane Stevens gave evidence on the opening day of an inquest into her son's death in March 2015. Photo: RNZ
Ms Stevens said the staff view that he did not want his parents involved seemed to have continued in the minds of staff.
"I have reviewed the clinical notes and there are more comments about Nicky's engagement with his family and about him wanting to involve his family."
Jane Stevens said the whānau and clinicians all had her son's best interests at heart but they had different opinions on how it was to be achieved.
She said what she wanted to come out of the tragedy was a much stronger collaborative relationship between clinicians and families of mental health patients.
"There wasn't that collaborative relationship even though it existed within DHB policy at the time, on the ground it wasn't operating."
Ms Stevens has made a number of recommendations to the Coroner addressing the issues.
Some notes on Mr Stevens' clinical care on the two days leading up to his death are missing. They were reported missing a few months after Mr Stevens died.
A former nurse at Waikato Hospital's mental health unit gave written evidence to the inquest saying she was mystified about how notes could go missing on a patient and that it was weird some of the hourly observation notes had disappeared. She said she and other staff were blown away about how it could happen.
The former nurse said Mr Stevens' file was taken by management once he went missing.
She also said staff in Ward 35 did not have a lot of faith in the unit's management due to staff shortages.
Coroner Wallace Bain has reserved his decision.
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