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Nicky’s death was “avoidable”, says Coroner

Nicky’s death was “avoidable”, says Coroner

Coroner Wallace Bain has formally found that our son and brother Nicky Stevens’ death was as a result of suicide.

That is one more figure to add to the awful suicide statistics in this country, but it is something our family has known since Nicky’s body was found in the Waikato River.

Nicky died while in the legal care of Waikato DHB’s mental health services, a ‘care’ that they legally enforced on more than one occasion, while not in practice ensuring Nicky’s safety.

Due to the obvious manifestations of illness, our family warned responsible DHB staff on several occasions, including in writing, that Nicky was at high risk of suicide, and should not be allowed out of his secure ward without supervision.

The DHB chose to ignore our warnings about the risk to Nicky, and as a direct result Nicky died, and the world is left without the contribution this talented young man would have made to it.

The DHB is responsible for our son and brother’s death, but has made no effort to support our family since that time, turning down several requests for direct support, and only funding minor counselling support for Nicky’s mother and brother over a year after his death after the family pleaded with the then CEO for help.

In 2016, the Independent Police Conduct Authority found that Police had also made a series of mistakes and omissions, when not commencing a search for Nicky until nearly 3 days after his disappearance. With credible evidence supplied to Police that Nicky was seen alive 24 hours after his initial disappearance, it is clear Police inaction also contributed to Nicky’s death.

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The family and friends funded significant legal fees relating to the Coronial case for some time until they ran out of money, and it was only the kind support of a family friend who was a senior lawyer that enabled the family to have any legal representation in the Coroner’s Hearing. At the same time, tens of thousands of taxpayer dollars were spent funding lawyers for the DHB and Police, while medical insurance covered the extensive fees for the lawyer representing the responsible psychiatrist. There was no level playing field.

Our family would like to thank Coroner Bain, the Coronial staff, and our lawyer Richard Fowler for their work and their empathy.

Our family would like to say to Waikato DHB, and especially to its leadership, that you should front up and make an unqualified apology for all the failings and shortfalls in your care for Nicky, and that you need to make good all of the missed opportunities to support us following his death. Without that sort of response, we will not have closure.

The Coroner’s findings and recommendations [italics are quotes from the report]:
[Para 191] The circumstances surrounding Mr Stevens death make it quite clear to this Court, that our mental health system is in urgent need of being overhauled and significant changes implemented.
[117] … is clear that the concerns raised by Mr Stevens family were real, and were not raised lightly. The Coroner adds that there is scope for improvement in the way that conversations are recorded in patients’ file notes.
[118] Families of those receiving mental health treatment, should feel involved……..Clinicians too need to be open to engagement to family. In many cases families have the most experience with their loved ones who are patients.
[136] The Court accepts Dr Honeyman’s view that the overriding history of matters as recorded in the notes, would not support unrestricted leave. Dr Margaret Honeyman was the independent senior psychiatrist employed by the Police to review the treatment of Nicky, and was called by the Coroner to give expert evidence to the Coronial Hearing.
[138] ….the Court agrees with the key points made by the Macpherson-Stevens whanau……it is evident that Mr Stevens wanted his parents involved with his treatment, as they had been for many years. Mr Stevens might have been improving, but he was still very unwell and acutely psychotic. In light of how ill he was, any risk analysis done was not sufficient, and ultimately the decision to grant unescorted leave enabled Mr Stevens to go down to the river alone.
[139] The recommendations suggested by the Macpherson-Stevens whanau at the conclusion of their submissions are well thought out and informed by their experience……I endorse them, and recommend that the Government and the Government Inquiry on Mental health consider them. These submissions are largely covered in the Coroner’s report but can be forwarded in their original form on request.
[141]It was clear from the evidence to the Court that both Ms Stevens and Mr Macpherson opposed unescorted leave and challenged the appropriateness of it. Waikato DHB claimed that Nicky’s family had not opposed unescorted leave for Nicky – a claim that was strongly challenged by the family. The Coroner finds that the family evidence was clearly correct.
[142]….the Court agrees with Dr Honeyman that the decision to grant Mr Stevens unescorted leave was unreasonable.
[146] The Court accepts the whanau submissions that Nicholas was acutely psychotic….right up to the 9th March. At issue was a suggestion by Waikato DHB that Nicky was getting better and that unescorted leave was an appropriate part of his treatment – the Coroner clearly agreed with the family’s contention that he was still acutely unwell on the day he did not return from unescorted leave.
[147] The Court accepts the evidence of Dr Honeyman. She reviewed all events and is very qualified. She points to several red flags in Mr Stevens behaviour. Whiles these red flags are undoubtedly made more prominent with hindsight, in the Court’s view they should have been identified at the time and acted upon…..the risk of suicide was always present, and therefore proper consideration of Mr Stevens’ risk should have been made. This did not happen.
[164] The Court agrees with the fundamental submission that, “there is an urgent need for an IPCA-like body to independently investigate complaints regarding serious incidents in a timely fashion”. It was submitted that the Health & Disability Commission is completely unable to fulfill this. Internal reviews are not independent enough and take too long. Health & Disability Commission staff told Nicky’s family in April 2015 that there was no point making a complaint to them until after the Coroner’s hearing had been held; many HDC complaints have taken well over 5 years to be heard.
[165] The Court agrees with the submission that there is an urgent need for an independently funded whanau advocacy service…These steps that need to be taken when those they are complaining about, such as DHBs, doctors and police, all have access to highly experienced lawyers to represent them. As noted, our family did not have the resources to fully present its views to the Coroner using legal representation – unlike ALL other parties, and it was only through pro bono support from a friend at almost the last minute that we were able to have some legal support. There was, and is no level playing field.
[168] …the recommendations made to the Waikato DHB, and all DHBs across the country is that while smoke-free policies and goals are to be applauded, it is recommended that consideration be given to provision being made for at risk patients to smoke in a safe environment. The family contends that it is all very well to have no smoking policies, but that if these do not take into account patients who are high and immediate risk, then those policies are short-sighted and dangerous, as proved to be the case for Nicky. There is ample room in existing and future acute facilities to provide secure smoking areas for high risk patients that do not impinge on the rights of other patients, or of staff.
[170] The submissions made by the Macpherson-Stevens whanau strongly suggest that family should be more involved in treatment decisions. Our family had to demand discussions with staff about Nicky’s treatment, with only lip service (at best) being paid to our views.
[172] It is clear however to the Court that this assessment was wrong in this case and that may well be because not all the appropriate information, particularly that held by the family, was given to the doctor finally making the assessment and giving the approval. Nicky’s responsible psychiatrist was not given all information held by staff about Nicky’s behaviour, and indeed gave evidence that she had not read all of Nicky’s file when she took over his care. That said, the information was available, had it been looked for.
[173] I recommend that the Waikato DHB review its consultation policies, and include steps to minimize differences between policy and family expectations. All DHBs should consider how consultation with whanau should occur, and how the results of it are recorded and acted upon.
[175] It is evident that there were delays in dealing with Nicholas Stevens’ failure to return at the appropriate time, causing further distress to the family. The reporting of Nicky’s absence was too late, breaching Waikato DHB’s policy in several ways, was missing vital elements. The Police response was a comedy of basic errors that meant that any opportunity to find Nicky alive was completely missed. Urgent requests for action to the Area Police Commander, the National Police Commander and the Minister of Police (Michael Woodhouse, MP) were not heeded.
[177] ….I recommend that the Waikato DHB implement a mechanism for review of escorted leave….. Waikato DHB had no active policy or guidelines for governing or recording leave, escorted or unescorted, enabling human error and laziness to impinge on safe practice.
[184]…..the Court is left with the clear view that the treatment Nicholas received was well short of what he and his parents would have expected. As a result of the deficiencies in his care, he was able to take his own life in the precise manner and place that he had previously said he would. This view is also strongly supported by the expert evidence of Dr Honeyman.
[187] Yet within mere weeks of him being admitted in the suicidal condition he was in, he was medically assessed as being able to take unescorted leave. He went on this leave to the Waikato River where he was able to take his own life, after he had very recently stripped off and “had a practice” there, which was known to the medical team who continued to permit unescorted leave. This is the ‘We told you so’ item. The family warned of this exact risk, but the DHB knowingly ignored the family warning.
[190] These findings are to be forwarded to the Minister of Health and asked to be reviewed in conjunction with the Findings of the Mental Health inquiry. Our family will be requesting a meeting with the new Minister of Health to discuss these findings – the previous Minister of Health refused to meet with us.

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