WARNING: This story deals with suicide 

A woman with a longstanding history of mental health problems meticulously planned her suicide, leaving notes on doors at her home for those who would eventually find her and several documents laid out including her will, farewell instructions and “useful numbers”. 

The 50-year-old New Plymouth woman had been detained in a locked ward and subject to 15-minute nursing observations when she was granted leave to return to her home for the weekend - despite being considered a risk of suicide and without any trials of unescorted leave. 

She was meant to have health professionals and a close friend supervising her but that plan was not confirmed before she left the ward. 

The woman had not long been home before she tragically seized the opportunity to end her life in January 2020. 

Now, Coroner Ian Telford has labelled the Responsible Clinician’s (RC) decision to grant her leave as “flawed”, saying it was made with urgency, out-of-hours and for reasons that have not been established. 

The coroner found her death was preventable and has referred the matter to the Health and Disability Commissioner for consideration. 

“On [the] balance of probabilities, I find it likely that her death would have been prevented if proper clinical processes were in place within HNZ [Health New Zealand] Taranaki, as they are now,” Coroner Telford said in his recently released findings. 

The 39-page report revealed that since the woman’s death and a subsequent Serious Adverse Event Review (SAER) by HNZ Taranaki, HNZ Taranaki has made a range of changes to how it manages in-patient care. 

Christine Lowry, regional director hospital and specialist services Te Manawa Taki, Health New Zealand - Te Whatu Ora, acknowledged the “huge impact of this tragedy” on the woman’s whānau and friends. 

“This is never an outcome we want when trying to help people experiencing mental distress,” she said in a statement to NZME on Monday. 

The findings, which determined the woman died in circumstances amounting to suicide, state she was engaged with mental health services for much of her life and had a history of several previous suicide attempts. 

An ‘organised’ suicide 

On January 9, 2020, she was admitted, under the Mental Health Act, to the mental health inpatient unit at Taranaki Base Hospital due to a deterioration in her mental state. 

On January 15, a support worker visited her on the ward and described her as “very relaxed and chilled out”. 

The following afternoon, they had a text message exchange in which the woman advised she was “going home tonight”. 

She had been granted four days of leave and left the ward that evening, driving herself home. No consideration was given as to her fitness to drive. 

The next day, on January 17, the support worker texted the woman but got no reply. She went to her house about 3.30pm and saw a note on the front door that said, “The back door is unlocked”. 

The woman was admitted to the mental health inpatient unit at Taranaki Base Hospital. 

After entering the house and gaining no response when she called the woman’s name, she saw some folders. On one it was written, “This is my will”. 

As she went past the bedroom, she saw a note on the door with a warning. The support worker did not enter and called emergency services. 

Emergency services arrived soon afterwards and the woman was found dead in the bedroom. 

Several other folders containing papers were found. The woman had laid out information on her finances, home, funeral and notes to various people. 

“The evidence shows that [her] planning was meticulous, organised and thorough. I consider those actions to be highly consistent with [her] intention to take her own life,” the coroner said. 

There were multiple mental health conditions recorded as contributing to her death. 

In an examination of the woman’s care, Coroner Telford considered the psychiatric care provided to her by mental health services – both historically and around the time she died, the SAER conducted following her death, which produced a range of findings and recommendations, changes HNZ Taranaki have made to their services since the SAER, and the opinion of a court’s expert concerning her care and the SAER. 

The plan was not clear 

The woman’s RC said in a statement referred to in the findings that at the beginning of her January 2020 admission, she presented as depressed, distressed, hopeless and confirmed she had a plan to end her life. 

However, on the day she was granted leave, she had agreed to undertake a form of treatment, which was due to begin the following week. 

“[She] requested to be allowed to stay home in the meanwhile. She denied any immediate suicide intent or plan at that stage and was then granted leave from the unit, after informing a close friend of hers ... whom she identified as her preferred contact and support person, of the leave plan,” the RC’s statement read. 

It said the friend was confirmed by the woman’s nurse in the inpatient unit and that she was to be supported by that friend on the evening she arrived home, and on the following morning by several named health professionals. 

But that was not how events played out. 

“It has become central to this case that [her] friend was not informed, and [the nurse] did not confirm the contact with her. None of the staff referred to above were aware of their planned involvement until after [she] died,” he said. 

Coroner Ian Telford conducted an inquiry into the 50-year-old New Plymouth woman's death. 

The nurse, who was aware informing the woman’s friend was a condition of leave and that it was his responsibility, did not tell the RC of his inability to ensure she was contacted. 

Coroner Telford made “a foundational assertion” that granting home leave under the Mental Health Act remained, at all times, the responsibility of the RC, even in the context of a functional multidisciplinary team. 

However, he noted “it is difficult to imagine the weight of such a responsibility”, and that also the woman had placed “considerable pressure” upon him to grant her leave request. 

It was preventable - on this occasion 

The findings stated she had not previously trialled unescorted leave, there was no consultation with the multidisciplinary team’s key members or whānau about her leave, and her risk assessment had not been updated. 

“The rationale for granting leave and her presenting risks were not clearly articulated or recorded and a plan had not been clearly articulated or recorded to facilitate the mitigation of risk. 

“This routine decision was made by the Responsible Clinician with urgency, out-of-hours, for reasons that have not been established. 

“The conditions attached to leave were not clear and the relevant papers required under the Mental Health Act had not been completed before [the woman] left the ward.” 

He said these “considerable” deficiencies in the decision-making process fundamentally compromised the RC’s decision to grant her leave. 

“The conditions made by the Responsible Clinician (which I find were inherently unclear) were not confirmed, clarified, or met before [she] left the ward. 

“Outstanding actions were not handed over within the nursing team. This meant that there was no protective process in place to help mitigate the risks associated with [her] home leave. 

“Therefore, the processes within HNZ Taranaki for operationalising the conditions attached to leave were inadequate at the time of [her] death.” 

The coroner emphasised the patient’s death was preventable on this occasion. “Being the only occasion for my consideration.” 

He said that if she had not had an opportunity that weekend to take her life, it was likely she would have attempted to do so on another occasion. 

“It must be restated that [the woman’s] needs were very complex, and I accept [the RC’s] comment that she had a ‘chronically elevated suicide risk … ' and presented with ‘significant clinical challenges’ throughout her long journey with mental health services.” 

In Lowry’s statement she said HNZ’s review has led to critical changes in the way it managed inpatient care, including around overnight leave and discharge planning. 

“Again, we would like to express our sympathy to all those who have been affected by this tragic loss of life.” 

SUICIDE AND DEPRESSION 

Where to get help: 

• Lifeline: Call 0800 543 354 or text 4357 (HELP) (available 24/7) 
• Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO) (available 24/7) 
• Youth services: (06) 3555 906 
• Youthline: Call 0800 376 633 or text 234 
• What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm) 
• Depression helpline: Call 0800 111 757 or text 4202 (available 24/7) 
• Helpline: Need to talk? Call or text 1737 
• Aoake te Rā (Bereaved by Suicide Service): Call 0800 000 053 
If it is an emergency and you feel like you or someone else is at risk, call 111. 

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.