The inquest into the suspected suicide of a Palmerston North Hospital mental health ward patient eight years ago has begun, with the coroner acknowledging the delay in the matter reaching a hearing.
Shaun Gray died in 2014. Photo: Supplied
Shaun Gray, a 30-year-old father of one, died on 16 April 2014.
An inquest into his death started in Palmerston North this morning.
Before the first witness was called Coroner Matthew Bates said some of the delay was unavoidable, but "all of it is regrettable".
"My hope is by reaching this point we can find some answers to exactly what has occurred."
Bates is the third coroner to oversee the case.
Coroner Matthew Bates is overseeing the inquest. Photo: RNZ / Jimmy Ellingham
Gray's death was followed a month later by that of fellow ward patient Erica Hume, 21.
Subsequent reviews found the ward not fit-for-purpose. A new one is under construction.
Bates read to the court a summary of the matter.
On 15 April 2014 Gray went to his Palmerston North pharmacy to collect his prescription medication and daily dose of methadone, a drug used to ease people away from addiction of other substances.
He was upset the pharmacist said they couldn't give him a takeaway dose.
Early in the afternoon Gray sent a text to his mother saying he'd "had enough".
She contacted health authorities, who said they were about to pick up Gray.
Gray subsequently collapsed and was taken to Palmerston North Hospital's emergency department.
He resisted treatment and was aggressive, saying he had overdosed on various drugs.
The next morning Gray said he was having suicidal thoughts and was taken to the mental health ward's high-needs unit. Later that day Gray was found unresponsive.
Members of Gray's family are present in court, although family spokesman, Shaun's brother Ricky, has said they won't be asking questions during, nor playing an active role, in the hearing.
He has said they are unhappy about a decision the coroner made concerning the way a key witness would give evidence.
The coroner told Gray family members they were welcome to take part anytime they wished, and acknowledged their grief.
"This process can bring back some of the feelings that you've experienced."
Nurse remembers Gray's hospital admission
A nurse, whose name is suppressed, said on 15 April 2014 Gray rang her upset about the decision made by the MidCentral alcohol and other drug services team to decline his request for takeaway doses of methadone for the weekend ahead.
Later that day Gray came into the service, where he collapsed.
The nurse was called to help. She became emotional when recalling the scene.
"I placed Shaun in the recovery position and I attempted to verbally, and by touch, to arouse him. Shaun was not responding."
The nurse waited with Gray until an ambulance arrived to take him to the emergency department.
The next day the nurse saw Gray, when he was in the department.
"Shaun was in a bed with restraints and presented as non-communicative.
"I asked Shaun if he had any plans to harm himself or take his life, and he said yes.
"I asked him what his plans were and he said, 'I'm not going to tell you.'"
The nurse helped Gray transfer to the mental health ward's high-needs unit.
She said she had known Gray for about four years and had never seen him behave the way he had been, biting and scratching staff and himself.
The nurse, who has about two decades' experience, noted Gray's medication had been reduced, which could have added to his distress.
At the mental health ward staff did not seem happy about Gray's admission, she said.
The ward was busy and short-staffed, and staff didn't concentrate on the handover nor ask questions.
"I've never had an admission like this, since or before."
Since then handover procedures had improved, the nurse said.
Concerns about medication
The summary read by the coroner said that when Gray was admitted to the high-needs unit questions were raised by staff about the level of triazolam he was prescribed.
Triazolam is used to help sleeping difficulties.
He was prescribed 0.625 milligrams, but staff thought the decimal point must have been displaced and the proper dose was 0.0625mg. Gray was able to show the higher rate was correct.
A doctor, who has interim name suppression, gave evidence about how he was in 2013 asked to review the prescribing practices of Dr Sarz Maxwell.
At the time, she worked for the MidCentral District Health Board. She prescribed Gray's medication.
Among its requests, MidCentral asked the doctor if Maxwell's prescribing practices were at significant variance to standard New Zealand practice, and if there was international evidence to support high doses.
The doctor told MidCentral he wasn't able to do such a review, but thought a formal inquiry should happen because it appeared Maxwell was prescribing high doses to patients.
He raised the possibility Maxwell was seeing more difficult or unstable patients, and sought the opinion of Dr Jeremy McMinn, a consultant psychiatrist and addiction specialist at Capital and Coast District Health Board.
McMinn wrote to the doctor in June 2013, saying there appeared to be "significant variance" in the doses Maxwell prescribed.
Maxwell had cited one patient as benefiting from high doses, but that patient was subsequently sent to prison, where authorities thought the drugs he was prescribed could kill him.
McMinn found it unlikely Maxwell was seeing particularly high-needs patients. He said he had prescribed high doses of methadone three times in six years and every time regretted it.
McMinn thought the matter should be referred to the Medical Council.
The doctor had no further involvement in the process.
Maxwell was from the United States and was practising in New Zealand under a provisional arrangement.
Former MidCentral chief medical officer Dr Kenneth Clark appearing before the inquest. Photo: RNZ / Jimmy Ellingham
Ricky Gray had completed a report into his brother's death and lawyer assisting the inquest, Tim Stephens, asked Clark about this.
Gray found Maxwell was under investigation in the US for falsifying her address and giving pre-written prescriptions before working for MidCentral.
Clark said he was aware of a "circumstance in the US", but couldn't remember the details. He said it was common for doctors coming from the US to have had concerns raised about them or having been subject to lawsuits.
"I would carefully peruse the nature of what the concern was."
The coroner asked Clark if he was aware of Maxwell's own substance abuse problems.
"Not at the time of her appointment," Clark said. "I subsequently became aware."
Maxwell was using drugs that in New Zealand were prescribed for opioid substitution treatment, but Clark would not disclose Maxwell's reasons for taking them.
Maxwell is not on the inquest witness list, but her methods are listed as a key issue in the inquiry, including her prescribing practices during or before she was responsible for Gray's care, and her prescribing a high dose of methadone for him in the first half of 2013.
Other issues included how often Gray was observed in the high-needs unit; had observation policies changed since 2014; and why staffing at the high-needs unit was below expected levels the night Gray died?
Following Maxwell's departure, Clark said appropriate guidelines were put in place for methadone prescribing.
And for patients on high doses, reductions in their medication needed to be carefully managed.
Resignation before investigation
At the time of Gray's death, Dr Kenneth Clark was the MidCentral chief medical officer.
He told the inquest how concerns were raised about Maxwell's prescribing practices in March 2013 by senior health officials, including the national director-general of mental health.
An audit of the methadone prescriptions was undertaken, finding Maxwell's clients were prescribed methadone at rates above the the guidelines.
Clark wrote to the doctor whose name is suppressed, and received his findings as well as McMinn's.
Clark then decided to limit Maxwell's ability to prescribe drugs at high rates, and plan to reduce the doses given to patients taking higher-than-normal doses.
He also decided there should be an investigation into her clinical practices.
Maxwell went on sick leave in August 2013 and subsequently resigned and returned to the US, so the investigation didn't happen.
The inquest continues.
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