Warning: This story deals with suspected suicide and may be upsetting.

Nicky Stevens planned his death, rehearsed it in the days before he died and attempted suicide once while in hospital care but, despite repeated warnings from his parents, the mentally unwell man was allowed out of care unescorted, his mother has told an inquest.

Jane Stevens and Dave Macpherson implored Henry Bennett Centre staff at Waikato Hospital not to let their 21-year-old son out of the medium-secure ward of the mental health facility without family, but their increasingly desperate pleas fell on deaf ears.

Instead a psychiatrist who had met Nicky once and assessed him without whanau involvement as previously agreed, deviated from a care plan put in place just days earlier and allowed Nicky - who suffered from disorganised schizophrenia - to leave the centre for cigarette breaks on his own.

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The day he went missing - March 9, 2015 - his mother rang the psychiatrist (whose identification is suppressed) and argued against the care plan change only to be told Nicky was considered low risk and the unescorted leave had been increased to three times per day.

Jane Stevens told the inquest at the Hamilton High Court today that little did she or the psychiatrist know that while they were having that phone conversation, Nicky had gone missing and no one had raised the alarm.

Nicky Stevens' body was found in the Waikato River three days after he left a mental health facility unescorted. His mother says he was a sensitive, gentle artist and musician. Photo / Supplied
Nicky Stevens' body was found in the Waikato River three days after he left a mental health facility unescorted. His mother says he was a sensitive, gentle artist and musician. Photo / Supplied

His body was found in the Waikato River three days later on March 12, and his parents' worst fears were realised.

In her 90-minute brief of evidence, Stevens asserted the psychiatrist either did not read or ignored Nicky's clinical notes where the family had raised repeated urgent concerns over Nicky's access to leave and his immediate risk to himself because of two recent suicide attempts, one that required surgery to recover from.

She described her "intelligent, sensitive" son, once a happy and healthy child, as behaving increasingly bizarrely in the weeks leading up to his death.

During a walk with her around Hamilton Lake on March 5 "he kept punching and kicking the air as if he was fighting someone".

"He would grab something and throw it to the ground. At one stage he rushed to me and grabbed something only he could see off my back and fought it to the ground."

Nicky told his mum he was fighting aliens and trying to protect his family and friends from them, that he had to die in order to save them.

He asked his friends to kill him and snuck down to the nearby Waikato River during unescorted leave where he told his mother he attempted to take his own life.

Stevens said her son was in the early stages of recovery from acute psychosis after he had been under-medicated without the family's knowledge for at least six months while in the care of Hauora Waikato.

Nicky breached his in-patient conditions at the mental health facility the day before he disappeared, but staff never told the family.

Instead Stevens said staff judged her and Macpherson, a Hamilton City Councillor and now a Waikato District Health Board member, as pushy, restrictive parents and alienated them from Nicky.

Jane Stevens told a coroner's inquest into the death of her son Nicky Stevens in 2015 he might still be alive if Henry Bennett Centre staff had listened to the family. Photo / Doug Sherring
Jane Stevens told a coroner's inquest into the death of her son Nicky Stevens in 2015 he might still be alive if Henry Bennett Centre staff had listened to the family. Photo / Doug Sherring

Stevens told Coroner Wallace Bain:

• The appropriate risk assessments were not made on her son;

• Nicky's clinical records at both Hauora Waikato and Waikato DHB were significantly "understated"; complete conversations with the family were omitted and different clinicians made contradictory assessments;

• The family were not included as they should have been and, in fact, it felt as if they were actively blocked in being part of their son and brother's care;

• His agreed leave conditions were not properly implemented or overseen;

• Staff did not adequately respond to Nicky's disappearance despite the fact he had told his mum in detail how he planned to kill himself and that he had tried to do it once while at the centre;

• And that Hauora Waikato had not provided a timely, safe or properly-resourced level of care for Nicky during the months leading up to his admission to the Henry Bennett Centre.

Stevens made a number of recommendations, including that patients recovering from an acute psychosis like Nicky need appropriate treatment strategies, that whanau must be listened to better and the DHB upgrade its whanau inclusion policy, clinical notes should be signed off by service users and their families and an independent advocate be available, and that a mediation service be created for families who disagree with clinicians.

Nicky's nurse - who has name suppression - painted a completely different picture of Nicky leading up to his death, saying the young man was eating and drinking well, was co-operative and appeared to be improving.

He said Nicky could have gone awol at any time because back then the courtyard for the ward had a small fence that many others had climbed over and escaped from.

But under cross-examination by Macpherson, the nurse admitted the wooden fence was 1.8 metres high and he conceded Nicky had bandages on his arms from surgery.

Bain asked why Nicky's parents were not informed of the plan change to allow unescorted leave and the nurse said he believed the psychiatrist had told Stevens of the change.

The inquest will hear from Nicky's psychiatrist and two other medical professionals tomorrow.

Timeline of events on March 9, 2015

The family of Nicky Stevens, from left, father Dave Macpherson, brother Tony Stevens and mother Jane Stevens want to get to the truth of why their son and brother died. Photo / Natalie Akoorie
The family of Nicky Stevens, from left, father Dave Macpherson, brother Tony Stevens and mother Jane Stevens want to get to the truth of why their son and brother died. Photo / Natalie Akoorie

12.29pm:

Nicholas Taiaroa Macpherson Stevens goes on unescorted leave. He is caught on CCTV kneeling in the foyer with his arms around his torso, swaying, but at least one staff member walks by, ignoring him.

12.45pm: When Nicky fails to return a psychiatric assistant tells his nurse.

1.15pm: Psychiatric assistant notifies Nicky's nurse again of the breach.

1.30pm: Nicky's friends arrive and ask for him.

1.57pm: Another nurse goes to look for Nicky.

2pm: Nicky's nurse rings Stevens to say her son is missing.

2.20pm: Stevens rings his flat but Nicky is not there.

2.30pm: Stevens rings the DHB in distress and speaks to the ward manager. The manager tells Stevens police are doing everything they can to find Nicky despite the fact Nicky has not been reported missing to police.

2.38pm: Nicky's nurse rings police northern communications centre, not through 111, and reports Nicky missing. The nurse gives a conflicting account of Nicky's risk of harm and no police are assigned to a search.

2.40pm: Stevens races to the Waikato River in Hamilton and finds no searchers.

4pm: Hospital security begin a search.

1am: A Henry Bennett Centre staff member notices a fax reporting Nicky missing to police has not gone through properly. The report is also incomplete.

March 11, 2015: Police begin search for Nicky.

March 12, 2015: Nicky's body is found in the Waikato River in Hamilton.

WHERE TO GET HELP:

If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.

OR IF YOU NEED TO TALK TO SOMEONE ELSE:

LIFELINE: 0800 543 354 or text HELP to 4357 (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
YOUTHLINE: 0800 376 633
• NEED TO TALK? Free call or text 1737 (available 24/7)
KIDSLINE: 0800 543 754 (available 24/7)
WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757