Man who died on mental health ward in 2014 was failed by staff - coroner

* Warning: This story contains discussion of suicide.

• Coroner releases damning report into 2014 suicide of Shaun Gray at Palmerston North Hospital mental health ward
• Says death was preventable and should have been avoided
• Hospital policies and procedures not followed
• Gray's family call for police to reopen investigation.

A man who died by suicide in the Palmerston North Hospital mental health ward 11 years ago was failed by staff who should have provided care to him, in a facility that was not fit for purpose.

Shaun Gray, a 30-year-old father of one, died on 16 April 2014, a death that coroner Matthew Bates describes in a comprehensive and excoriating report released today as avoidable.

The ruling comes three years after an inquest into the death and years of delays before that as the case was passed between coroners.

Gray's method of death is suppressed, so some of the coroner's criticisms about that can not be reported.

However, among the "factors that… contributed to Shaun's death" was poor communication, including the absence of a one on one handover between the community key worker and the receiving nurse at the ward, known was ward 21, when Gray was admitted.

That nurse failed to review key documentation about Gray, including his risk assessment that described his suicide risk.

"This broke the chain of vital information which should have been known by ward 21 staff throughout each shift, and which would likely have affected the manner in which Shaun was nursed, particularly in relation to regular observations of him," Coroner Bates said.

Gray was admitted to the ward's high-needs unit, which had strict observation policies requiring checking patients at least every 10 minutes. Gray though was left unchecked for more than an hour before he was discovered unresponsive in his room.

Required staff-to-patient ratios were also frequently not met, the coroner found.

Coroner Bates said Gray's mental state was a factor, including frustration at not being allowed a takeaway dose of methadone at his pharmacy on 15 April; distress at his admission to the high-needs unit rather than the ward's open section, where he'd stayed before; and an incorrect dose of medication offered to him.

"I find that Shaun's death was avoidable and should have been prevented," Coroner Bates said.

"The combined impact of the failings described… was that Shaun had the means and opportunity to end his life."

Policies and procedures at the ward's high-needs unit were adequate, and if they were followed Gray would not have died, the coroner said.

"I find that it was a failure by management and staff to ensure those policies were adhered to which resulted in Shaun receiving substandard care, and which ultimately enabled him to take his own life."

Gray's death was followed a month later by that of another ward patient, Erica Hume, 21, and there have since been more deaths.

Reviews following Gray and Hume's deaths found the ward not fit for purpose and a new $60 million ward is under construction, expected to open in the middle of the year.

Family want police to reopen case

Police investigated Gray's death, but in 2016 confirmed they would not press charges.

However, Gray's brother Ricky told RNZ having seen the evidence gathered by the coroner about the nurse who left Gray unsupervised, the family would be writing to police, requesting they take another look.

"Furthermore, we will be reaching out to the Nursing Council to inquire about any sanctions or investigations into the nurse's conduct, given that they were permitted to continue practising."

Ricky Gray said the family were grateful for the coroner's work, albeit that it took almost 11 years.

"I think there's one paragraph out of the entire findings that we draw upon from Coroner Bates and that's his finding that Shaun's death was preventable and should have been prevented, and that the impact of the combined failings was that Shaun had the means and opportunity to take his own life."

The family would also like to see a law change ensuring coronial recommendations are enforced.

They were not consulted about planning for the new ward and said the only involvement they wished to have was in the demolition of the present ward.

"We will continue to seek justice for Shaun, and we will fight for the necessary changes to prevent other families from suffering the same heartbreak that we have endured."

How did Gray end up alone in his hospital room?

On 15 April 15 2014, Gray went to his pharmacy to get prescription medicine and his daily dose of methadone - something opioid addicts take to ease their dependence on substances.

Gray had long-standing addiction problems and started the methadone treatment programme in 2004.

As he was planning to go away for Easter weekend, Gray asked for a takeaway dose of methadone, but was told this was not possible.

Unhappy, he rang his MidCentral alcohol and other drug service key worker, who collected him.

At the service he collapsed, after saying he had taken something and that he "wouldn't be here tomorrow". He'd also texted his mother saying he had failed at rehab and at life, and had enough.

Gray was taken to the hospital emergency department, where he was aggressive and resisted treatment for his overdose and for injecting himself with hydrofluoric acid. He said he wanted to die.

He was placed in restraints and later that night he was assessed by specialists, who were concerned about Gray's risk to himself. They thought he should be detained under mental health compulsory treatment laws.

The next morning he continued to say he had plans to hurt or kill himself, and he was admitted to the mental health ward at 11am.

On a shift handover a nurse, whose name is permanently suppressed, was assigned to care for Gray. The coroner said the handover form given to the nurse on the afternoon shift did not adequately explain Gray's risk of self-harm.

During the evening of 16 April Gray became upset due to confusion over his medication doses, and at 9.40pm called his dad, angry and frustrated, then returned to his room.

At 10pm the nurse assigned to care for him left the high-needs unit to do paperwork. They later admitted they were terrified of Gray and wanted to minimise their time spent with him.

The coroner said if that were the case the nurse should have told their charge nurse, rather than "adopt a practice of avoidance".

Another nurse, whose has interim name suppression, was assigned to care for Gray on the next shift handover at 10.45pm.

They and a fellow nurse at 11pm noticed Gray's room had a sheet over the outside of the door, preventing a view inside. They found Gray, but he could not be revived and was pronounced dead at 11.20pm.

Recommendations

Coroner Bates made 15 recommendations.

He said admission documents for the mental health ward should be completed when a patient arrives, or during the same shift at least.

"The admission nurse should turn their mind to admission paperwork at an early stage to ascertain the purpose for the patient's admission and their risk profile."

The coroner said clinical notes should be completed frequently and in a timely manner, and the patient handover template should have specific sections on risk of self-harm, suicide, or risk to others.

He said psychiatric assessment should happen as soon as possible after admission to the ward.

Coroner Bates echoed reviews after Gray and Hume's deaths, saying the ward was not fit for purpose.

"All available steps should be taken to ensure the new inpatient facility currently under construction opens as soon as possible, to ensure mental health service users in the region can receive the best available care in a much safer environment than the current ward 21."

Medication concerns

Coroner Bates also recommended more robust inquiries about and greater supervision of overseas doctors employed to work in New Zealand, and adherence to policies and guidelines when prescribing methadone.

He made this recommendation because in late 2012 Gray was put under the care of Dr Sarz Maxwell, who was hired that year from the US.

Maxwell dramatically increased Gray's methadone doses - which more than doubled to 390 milligrams a day by January 2013 - as well as those of other drugs.

After Maxwell left, Gray's doses were then reduced, and he spent six weeks in the hospital mental health ward's open wing for this purpose in 2013.

MidCentral sought an independent review of Maxwell's prescribing practices, and they were found significantly out of step.

After being told of a further review, Maxwell took sick leave then resigned.

The coroner said in the US she was put on a probationary licence in the 1990s, and was the subject of a malpractice suit after a patient died of a methadone overdose. The case was settled out of court.

Coroner Bates said a central question at the inquest was whether variations in Gray's medication contributed to his death.

He said she held a different philosophy for addiction treatment than was found in New Zealand.

"With the benefit of hindsight it is clear that Dr Maxwell was a poor fit for practice in New Zealand and should not have been approved to practice here."

The coroner also said there was a serious breakdown in communication channels at the then MidCentral District Health Board. He said it was difficult to understand why the clinician who supported her application to move from provisional registration in New Zealand to full did so, given the review of Maxwell's practice.

Experts told the coroner's inquiry reductions in Gray's prescriptions after Maxwell left didn't contribute to his state of mind in April 2014.

Health NZ says changes made

Health NZ MidCentral chief medical officer Dr Claire Hardie said she extended her condolences to the Grays for their loss, and acknowledged there had been further deaths in the years since 2014.

"We review every serious adverse event that occurs in our hospitals and make changes to ensure we are providing a high quality and safe service for the community. Significant changes to our practice have been made following these tragic events to prevent them happening again," she said.

"Specific actions have been taken in terms of admissions documentation, handovers and observation."

There had been changes to the observation policy to better support patients with increased risks, and observation forms required detailed information.

The ward's handover practices had been strengthened, and other changes included improvements to medication dispensing.

"We have also undertaken significant work to improve conditions and team culture for our staff. We have increased our staffing levels on ward 21, including new leadership roles and implemented Care Capacity Demand Management.

"This has been supported by a comprehensive training programme on risk assessment documentation, policy, observations, communication, and handover processes that all attend.

"Professional recognition development programmes are also now in place for every member of the nursing team," Hardie said.

Meanwhile, doctors recruited from overseas were supervised by senior medical officers.

"We are sorry that these improvements in our system came too late to help Shaun and prevent the immense loss that Shaun's family have experienced."

Health NZ was asked if anyone had faced disciplinary action over Gray's death, but it said it did not comment on individual employment matters.

Where to get help:

• Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
• Lifeline: 0800 543 354 or text HELP to 4357.
• Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
• Depression Helpline: 0800 111 757 or text 4202.
• Samaritans: 0800 726 666.
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
• What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
• Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
• Rural Support Trust Helpline: 0800 787 254.
• Healthline: 0800 611 116.
• Rainbow Youth: (09) 376 4155.
• OUTLine: 0800 688 5463.

If it is an emergency and you feel like you or someone else is at risk, call 111.

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