Joe Carter was living in a windowless room in a mental health hospital, sleeping in “manky sheets” on a mattress on the floor with his belongings in a rubbish bag, when he died by suspected suicide.

Now an inquest into Carter’s death on August 25, 2019, has heard the 35-year-old was potentially facing homelessness again when he left the centre for his usual walk and never returned.

His death came a month before the Ombudsman conducted inspections of the Henry Rongomau Bennett Centre [HRBC] that found severe overcrowding and patients subjected to degrading treatment.

When his mother Jenny Carter visited the room inside Waikato Hospital after her son’s death, she found a Trade Me list of flats for rent.

Carter was being discharged the next day but despite sometimes having to sleep in another ward, in the lounge with a blanket, or in the windowless interview room, he was unhappy with the community accommodation and his mum believed that was a warning her son was not well enough for discharge.

Carter had paranoid schizophrenia and had suffered psychosis for two years while being in and out of the HRBC and under community mental health care.

At one stage Carter was living in a leaking caravan with no power or water on his father’s property.

While relapsing Carter assaulted his mother’s partner who had cancer, and his brother, damaged the family’s letterbox, and was being treated with the antipsychotic medication Olanzapine which made him sleep up to 18 hours a day.

But the inquest, presided over by Coroner Alison Mills, heard when Carter was well he was a bright, quiet, kind and caring man, a former Australian outback station stock manager, and a talented musician who at one point had a recording studio in his home.

The Henry Rongomau Bennett Centre was the subject of a scathing report by the Ombudsman in 2020 after it was found patients were subjected to degrading treatment. Photo / Michael Craig

Overcrowding, involvement of whānau in care, allocation and supervision of unescorted leave, absent without leave (AWOL) response, risk assessments and adherence to policies were issues traversed during the four-day inquest at Hamilton District Court.

The centre’s operations manager, Kylie Balzer, called it “heartbreaking” that Carter had to live in the converted interview room.

“No one’s loved one should have to sleep in an environment like that.”

Balzer said the biggest lesson from the “tragic death” was to listen to whānau.

The inquest heard when Carter was suffering paranoia he didn’t want nurse Mary Bennett to talk to his parents and she obeyed this.

Bennett also allowed Carter out for 30 minutes for his usual walk on the day he died but did not report him missing when he failed to return at the agreed time.

During questioning from Simon Mount, KC, assisting the coroner, Bennett said she had no idea Carter might be spitting out his medication despite multiple references “in flashing lights” in his notes of non-compliance.

She also did not think her “client” was at risk on unescorted leave because he was being discharged the next day and she wasn’t worried when he didn’t return because he could have up to two hours’ leave.

This was despite his previous attacks on family members when delusional and the need to alert them to him being missing for their own safety.

Ninety minutes after he left, Carter was reported dead but an AWOL response was not initiated for another 45 minutes.

When asked why Bennett said: “We were all in shock”.

His mother had been advocating for her son and trying to get him off Olanzapine and onto Paliperidone for two years but felt she was not being listened to by clinicians.

She did not know Carter had schizophrenia until a nurse told her in passing and would later learn that long-term psychosis had damaged her son’s chances of recovery.

On paliperidone, Carter’s illness improved but a few weeks before he died, during his last admission to the HBRC, psychiatrist Dr Jean Erasmus switched Carter from paliperidone injections at his request to an oral antipsychotic, despite Carter having a history of not taking his medication.

Erasmus said Carter’s insight was improving when he agreed to trial the medication in an effort to create rapport with his new patient, but concerns were raised Carter was still delusional and that he might not take the medication and it might not be effective.