A coronial inquiry's heard that a mental health patient who died of suspected suicide while in a secure unit had a history of self-harm and suicide attempts.
The Coroner in Wellington is looking into the death of Samuel Fischer, who was 34-years old when he died by suspected suicide in April 2015, while he was a patient in a secure mental health unit.
Mr Fischer had an extensive mental health history dating back to 1995, with major bipolar affective disorder complicated by cannabis and alcohol abuse.
Detective Sergeant Terence Fraser told the inquest the police had recorded seven incidents where Mr Fischer had self-harmed or attempted suicide since 2000.
On the morning of his final attempt in the secure unit, DS Fraser said Mr Fischer had repeatedly banged his head against the bathroom wall, damaging it.
He said staff assessed him, and they noted Mr Fischer had said he was tired of it all and wanted it to be over.
Once his mood appeared to have improved later in the day, Mr Fischer told a nurse observing him that he wanted quiet time to play the guitar.
That nurse left his room around 5.20pm and said they would be back in an hour, the officer said.
Mr Fischer was aware he had a 40-minute window in which he would be unobserved, the officer said.
Mr Fischer was unresponsive and had no pulse by the time he was next observed around 6pm, the officer said, and he died three days later in intensive care in Wellington Hospital.
DS Fraser said there was no evidence of any other person being involved in the death, or of Mr Fischer having taken any other drugs than those he had been prescribed.
The mental health unit, Te Whare o Matairangi, conceded its documentation on Mr Fischer was not up to scratch.
A doctor in the unit told the inquest there was no clear risk management plan, or clinical treatment plan, for Mr Fischer easily or readily available in one document.
She accepted that may have made it harder for nurses - who decide how often a patient should be observed - to look after Mr Fischer.
She said if Mr Fischer were observed more frequently, or "if seen for any reason in the 30-40 minutes [he was alone], the outcome could have been very different".
However, she disagreed that the absence of such a plan stopped nurses from being able to make an overall judgment on the situation; and said she disputed whether that was even a contributory factor.
She acknowledge the distress Mr Fischer's family had experienced, saying it was a terrible event to lose an adult child to suicide especially when he was an inpatient in a mental health unit.
However, she also said Mr Fischer's mother, Lyn Copland, and advocate Jak Wild placed the "most extraordinary demands" she had experienced in 10 years in her role.
The inquest heard that at times, Ms Copland's visits to her son were restricted and that he felt increasingly trapped in the facility throughout his 10 weeks there.
Ms Copland's lawyer Letizea Ord asked why Mr Fischer - a capable musician - could only use therapeutic facilities such as the music room once a week, the doctor agreed that was frustrating but resources were tight.
The doctor said it was important patients could access those spaces, but mental health facilities throughout the country faced constraints and had to prioritise their resources.
The inquest heard that Mr Fischer's mental health was taking a long time to stabilise.
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