The death of a Palmerston North Hospital mental health ward patient, whose body was found metres from the building six days after he disappeared, has been ruled a suicide.
Simon Oakley, of Ōtaki, was a voluntary inpatient at ward 21 for more than three weeks in June 2017.
On 24 June that year the 41-year-old took leave from the ward and didn't return. His body was found by police search and rescue staff in bushes near the ward's entrance on 30 June.
In a decision reached after an inquest last year Coroner Tracey Fitzgibbon has ruled the death as self-inflicted on 24 or 25 June.
She didn't make recommendations.
Oakley's death is one of several of patients at the ward since 2014.
It's accepted the ward is not fit for purpose and a new one is expected to open later next year or in 2024, well after the originally expected late-2022 construction date.
Psychiatrist Dr Malcolm Stanton told the inquest Oakley was frustrated at the pace of his progress, but had good insight into his mental health. He had suicidal thoughts before his admission to the ward, but these receded.
Oakley took leave from the ward twice on 24 June, returning after the first one. Before each period he was assessed by a nurse.
The last sighting of him was at a dairy across the road from the mental health ward.
Police were told he was missing that afternoon.
Hospital security staff searched around the ward, also that afternoon, and other parts of the hospital grounds on 26, 27 and 29 June, but found nothing.
Security services manager David Christophers said the later searchers didn't relook at the area around the mental health ward, where Oakley's body was found in an area of bush.
"We had assumed, wrongly, he would not have come back on the Saturday and been beside ward 21," Christophers said at the inquest.
He said security staff weren't trained for searches and relied on their knowledge of the grounds and where people had previously hidden.
On 30 June, the search and rescue workers found Oakley's body after about 25 minutes.
Among issues identified in a report by the MidCentral District Health Board were that the hospital security manager could have been contacted out of hours to review CCTV footage sooner, and the delay in finding Oakley's body.
A following external review found there were "no obvious systemic failings" that led to Oakley's death.
This analysis supported recommendations made in the MidCentral assessment that care plans take note of the value of family contact; review staff understanding of risk assessments and communication about this across shifts; and review search procedures.
The then-chief executive of the health board's mental health and addiction services Vanessa Caldwell told the inquest that policies were not as clear as they could be and needed improvement for who took responsibility, such as with searches.
After Oakley's death the health board introduced a new risk assessment tool; updated clinical risk assessment training for staff; and reviewed and updated leave procedures.
Christophers said security workers would now immediately obtain more information about missing patients and call in extra staff if patients hadn't returned within 72 hours. Areas of vegetation had been cleared and more CCTV cameras installed.
"After reviewing all evidence, including oral evidence, I am satisfied that, on a balance of probabilities, there are no factors in the care of Simon which contributed to his death," Fitzgibbon said.
There was no evidence Oakley's suicidal thoughts continued after his admission, he had previously taken periods of leave without a problem and there was no indication he intended to die by suicide when he left the ward on 24 June.
The coroner was also satisfied there were no problems with the police investigation.
"Although the family had questioned why the search and rescue team had not been deployed earlier, it was apparent that in the initial stages this was no required and therefore not deployed until 30 June."
Fitzgibbon said the hospital searches by security staff were within their training.
MidCentral mental health and addictions operations executive Scott Ambridge said the board was reassured the coroner didn't find fault nor substantial gaps in Oakley's care.
Ambridge said the new process for patients requesting leave had staff asking a wider set of questions about how a patient felt and the state they were in.
And since the coroner's report was published, more changes had been made.
Leave was now granted more gradually, beginning with patients being escorted by staff or family. The mental health ward allowed patients to vape in its outdoor courtyard, reducing the number of patients needing to take periods of leave from the smokefree hospital grounds.
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