2 May 2022

Family to boycott coronial inquest after decision to excuse witness

11:50 am on 2 May 2022

The family of a man who died in a suspected suicide at Palmerston North Hospital eight years ago are boycotting a coronial inquest later this month.

Palmerston North Hospital. Photo:

Shaun Gray's family say they are walking away because they can not question a key witness at the hearing.

The 30-year-old father of one died in Palmerston North Hospital's mental health ward on 16 April 2014.

An inquest into his death is finally due to begin in Palmerston North in four weeks before Coroner Matthew Bates.

Shaun's brother, family spokesman Ricky Gray, said after years of preparation they wouldn't be there asking questions on Shaun's behalf.

Shaun Gray, a mental health patient who died on 16 April 2014

Shaun Gray died in a suspected suicide at Palmerston North Hospital's mental health ward in 2014. An inquest into the death will begin this month. Photo: Supplied

That is because they are unhappy with the coroner's decision to excuse a key witness from appearing at the hearing in person.

"With Coroner Bates' decision to exclude the most fundamental witness, this is a practice we don't want to condone," Gray said.

"We feel carrying on with the inquiry on the basis of the decision is accepting the decision."

Families often represent themselves in inquests due to the difficulty of obtaining legal aid and the cost of hiring a lawyer.

A statement from Coroner Matthew Bates said an application to give evidence using an alternative mode was granted for one witness.

"All parties have an equal opportunity to elicit evidence from that witness, including questions with affirmed responses prior to the inquest hearing and supplementary or follow-up questions after the conclusion of all other evidence.

"If the coroner determines the response to any question appears incomplete or unsatisfactory for any reason, the witness will be required to provide a further affirmed response."

A suppression order means RNZ can not say why the decision was made, or who the witness is.

Gray said it was more frustration after years of waiting.

"Thousands of hours have gone into this inquiry. We've trawled through thousands of documents from the Ministry of Health, the Health and Disability Commissioner and the [MidCentral] DHB.

"We've examined many sentinel events that had occurred before Shaun had passed and also post Shaun."

The family had reviewed Shaun's death and the lead-up to it, including concerns about the increased medication prescribed to him as he faced his mental health and addiction difficulties.

Although they would not take part, they would still follow proceedings at the inquest.

"For us it's about sitting back, waiting and almost testing the coronial process. We'll see what Coroner Bates delivers and we'll see what he decides to look at in the inquiry.

"We want to compare recommendations or if the coroner wanted to initiate change and give the DHB the wake-up call it so urgently needs."

Gray said there was often a pattern with similar cases across New Zealand, and the family would like to see a wider inquiry into some of the issues Shaun's circumstances raised.

"We seem to be splitting these recommendations across districts. There doesn't appear to be any global or nationwide entity that's actually putting together recommendations...

"It's always the same issues - failure to do a risk assessment on someone that has arrived at a mental health ward. It's just unacceptable."

Auckland lawyer Moira Macnab said families at inquests should get the same level of funding for lawyers as that spent by organisations such as, in this case, the MidCentral District Health Board.

She was also appalled by the time it had taken to get an inquest.

"The real difficulty with the delay is families don't start really grieving until after an inquest, so eight years is terribly traumatic for the family," Macnab said.

"I think that, sorry, eight years is not good enough and I'm sure the coroners office would agree with that."

Some of the delay is because Shaun Gray's coronial file was passed between coroners. Coroner Bates is the third to examine the death.

"Inquests are really important and they are actually the oldest courts that exist," Macnab said.

"These operate as a release valve. If people know things are being looked at properly they can cope when things go wrong and they can realise that there can be improvements and that we can do things better."

After the deaths of Shaun Gray and another patient, Erica Hume, in 2014, audits found the mental health ward not fit for purpose.

A $35 million replacement ward was to open later this year, but documents obtained by RNZ show health officials expect that to be pushed out by 12 months.

A MidCentral status report for the work from September showed it was expected construction on the new ward would finish in November 2023 and the ward would open the following month.

It is understood that more recently, health officials have cited 2024 as an opening date.

Gray said his family were distressed at the new ward's slow progress.

It was announced by the government in 2019. Prime Minister Jacinda Ardern visited the present ward and said it was more like a prison than somewhere where people could recover from a crisis.

It was disturbing to see no earthworks on the site of the new ward, Gray said.

"We're talking eight years and we've still got a ward that's unfit for purpose, and we keep hearing of other deaths."

That included two last year - a patient in the mental health ward and a man waiting to be assessed by a mental health team after being admitted to hospital with self-inflicted injuries.

New ward nearly complete

In a statement, MidCentral mental health and addictions operations executive Scott Ambridge said the "developed design" phase for the new ward was nearly complete.

"This has included, for example, the redesign of the entranceway, led by iwi in partnership with the clinical team, to ensure this is a welcoming and culturally responsive space for all."

It will be followed by the "detailed design" phase looking at landscape, furnishings, fixtures and equipment.

"We anticipate being able to engage contractors and commence siteworks by spring. At that point we will be able create a construction programme to give a more definitive date for the ward's opening."

To ensure all needs were met, MidCentral had taken "some additional time" for independent reviews, including looking at cultural, architectural and functional perspectives to reduce the risk of changes being required later, Ambridge said.

"That timing has taken us to the start of winter, which makes it undesirable to commence excavation and so we have adjusted our programme accordingly."

The new ward would have 28 beds and two low-stimulus suits. The ward was designed to allow for future expansion of another eight beds.

Ambridge said the ward's cost could be reviewed because of the effects of Covid-19 on the construction industry and supply chains.

Meanwhile, more than seven years on from Shaun's death, Gray said his family was remembering his brother as a lover of nature, and a person committed to supporting other people who used mental health services.

Get the RNZ app

for ad-free news and current affairs