Mararau Williams and his mother Martha. He battled mental health issues and drug addiction for many years and took his own life when he escaped from a specialist unit. Photo / Supplied
WARNING: This article is about suicide and mental health
A mental health inpatient considered a “flight risk” after an earlier escape attempt managed to flee during a “poorly executed” ward transfer - taking his own life hours later.
Mararau Maurangi Williams, 24, should have been watched every second while he was moved between wards at Middlemore Hospital’s secure mental health unit.
However a Coroner has said “an apparent casualness” amongst staff meant he was able to run out an open door when their backs were turned.
Williams died on July 27 2019 but the coronial investigation into his death was not complete until March this year.
Coroner Katharine Greig formally ruled Williams’ death a suicide and said he may still be alive if his hospital care had been better.
“At the time Mararau absconded he was… clearly not being closely observed as he was not observed departing.
“That Mararau may attempt to abscond if provided with the opportunity ought to have been something the health professionals caring for him were alert to and vigilant about.
“The evidence shows that the transfer process was poorly executed.
“If he had not absconded, it is highly unlikely that he would have died when he did.”
Williams’ mother Martha said she had fought for months to get her son the high-level help he needed and she was devastated he was failed by the very people who should have kept him alive.
“My boy needed help… it was a relief when he went into the unit,” she said.
“I thought ‘right, someone’s going to take the time to have a look at him’,”
But days after Williams was admitted, Martha’s worst fear became reality - her son was dead.
Williams was a “cheeky fella” growing up - a boy who loved music, sport and family.
“He could play anything he picked up… he had so many gifts,” Martha said.
“And then he just got on the wrong track.”
When he was about 11 or 12 Williams started using drugs and alcohol and by his mid-teens he was battling addictions.
At the time of his death, he was a regular user of methamphetamine and had told his GP he “was not ready to stop using”.
“He had had escalating episodes of psychosis since 2016, which were deemed to be drug-induced psychosis,” said the Coroner.
“He had also had a history of behavioural problems linked to impulsivity and emotional dysregulation that were probably worse when he was intoxicated.
“In this context, Mararau had had a number of acute presentations to Community Alcohol and Drug Services and mental health services but had been discharged when he declined to engage.”
Williams spent time in prison for criminal offending and while inside was prescribed mood-stabilising medication that appeared to help him.
When he was released he went to his GP and said he wanted the help of mental health services, but again, failed to engage further.
His mother was also becoming increasingly worried about him.
“She was keen to have him assessed and treated, but in the face of Mararau’s unwillingness to engage with CADS or mental health services had been unable to find a way to get him the treatment she felt he needed,” said the Coroner.
July 2019 marked the beginning of Williams’ last spiral.
Police were called to his family home and his aunt’s home in the same day when family became extremely concerned and “frightened” about his behaviour.
His aunt said he appeared to be “high on drugs” with “wide open eyes and couldn’t keep his head or hands still and was extremely agitated”.
Later that day Williams told his mother he had not been taking his medication.
He had talked about suicide, he was paranoid, he was hearing voices and he was seeing people.
“I begged and begged him to go to hospital,” Martha said.
“I finally got him to agree - I was so afraid he would hurt someone, but I never, never, never thought and he never showed or told me that he would hurt himself.”
Williams spent the night in Middlemore Hospital’s emergency department with methamphetamine intoxication and underwent a mental health assessment the next day.
He was admitted to a respite facility but when he barricaded himself in his room there police were called and he was taken to Tiaho Mai, Middlemore’s acute adult mental health inpatient unit.
Doctors there asserted Williams either had drug-induced psychosis or underlying schizophrenia and anti-social behaviour and he was admitted to a high-care secure ward where patients are locked in with no leave allowed.
On the second day he was there Williams was seen trying to climb a courtyard fence in an effort to escape from the ward.
He later told his doctor that the secure ward made him feel ‘trapped” and reminded him of the time he spent in prison.
Over the next couple of days Williams’ condition improved - he reported he was still hearing voices but was considered to be “almost in remission” of his psychotic symptoms.
His doctor noted he was not experiencing a major depressive illness nor was there “imminent risk of completing suicide”.
On that basis, it was decided Williams could be moved to a “flexi” secure ward - a locked ward that was less restrictive.
Coroner Greig said the doctor “considered, and documented” that Williams was a ‘flight risk’ and that when he was moved he needed “close supervision”.
Williams “gave him an assurance” that he was not going to “take off” from the unit and was willing to accept his treatment.
On July 26 Williams assigned nurse was busy and asked a colleague to do the transfer.
That nurse collected the patient and walked him to the flexi ward - where his room was not ready.
As they waited in an unlocked area, the nurse turned way from the patient to give “a very brief, approximately one-minute” to another nurse.
As they chatted, Williams scarpered through the open entrance doors.
When staff realised Williams was gone they searched for him, then instigated the “absent without leave” procedures which involved alerting Williams doctor, the relevant managers, police and his mother.
Martha said knew her son would try and come home so she tried to stay up to meet him and help him when he arrived.
She fell asleep at about 10.30am but woke at 3am and looked for her son in the house and his bedroom in the sleepout.
He was not there.
At about 9am Williams’ father discover his body in the sleepout.
A post mortem examinatinon revealed Williams had, along with prescription medication, methamphetamine in his system.
The Herald cannot report exactly how he died, but the drugs were not related.
“It is not possible to conclude that Mararau’s death would have been prevented if he had not absconded during the transfer,” said Coroner Greig.
“However, I have formed the view that Mararau was presented with an opportunity to abscond that ought not to have occurred.
“If he had not absconded, it is highly unlikely that he would have died when he did.”
Coroner Greig said the Williams’ transfer was “marred by poor communication between the wards”.
“With the new ward not ready to receive Mararau, with his room not made up and the ward not locked when he arrived; poor communication from the nurse assigned to Mararau’s care to the nurse undertaking the transfer about the risk of Mararau absconding and an apparent ‘casualness’ amongst the staff involved about the risks inherent in the transfer process,” she said.
The Coroner said there was no issue with the way staff responded after Williams disappeared and she was satisfied the hospital had taken steps to prevent similar situations in future.
She said an internal investigation undertaken after his death aimed to “look for improvements in the system of care and establish how recurrence could be reduced or eliminated”.
Te Whatu Ora Counties Manukau advised the Coroner it last reviewed its policy for the transfer of patients within Tiaho Mai in September 2022.
“A copy of the policy was provided to this inquiry. It sets out a clear process for transferring patients between high and low-dependency units based on assessing the risk and needs of the patient.
“The responsibilities of all staff concerned with a transfer are set out. On this basis, I do not consider it necessary to make recommendations.”
Coroner Greig said Williams’ death was, sadly, not unique in New Zealand.
“This is not the first death I have dealt with where a patient of an acute mental health unit has absconded whilst being transferred to another ward and subsequently died as a result of suicide.
“Transfer of patients between acute mental health inpatient units is a process that presents potential risks for patients to abscond and must be treated seriously on every occasion – with risks assessed for each patient and appropriate plans put in place including ensuring that the receiving ward is ready to accept the patient before the patient is moved, and the staff member responsible for the transfer is cognisant of the risks associated with the particular patient and has in place an appropriate plan to mitigate such risk.”
Martha Williams said it was heartbreaking to think her son could still be alive if he’d been watched more closely.
“He was a ratbag, but he was my child,” she said.
“He was very loved, he just wanted to belong… I tried for months to get him help, I tried everything… but he wasn’t willing to engage and that made it harder.
“It was so scary… making the call to put him in the unit under the Mental Health Act - I made the final call, I made the decision, I thought it was the right thing to do.
“I was trying to protect him from himself…I feel like no one heard us.”
Martha, whose husband died 14 months after her son in a tragic boating accident, said she wanted to speak up for her son and make sure people knew his story.
She hated that she had to go to such extreme measures - getting Williams locked up under legislation - to get him help.
“I feel like we were failed… the door was closed, but behind that door was a family and a boy that needed help.
“You just need to fight, and fight, and fight and keep knocking on doors… we were left on our own because it was ‘too hard’ to help.
“I wanted my son to be heard.”
Martha said her son had his troubles but she wanted people to understand that he had a good heart.
“I was very proud of him, I want everyone to know that his mother loved him - even through the hardest times.
“I want people to remember him as a boy who made his mum smile, every in the naughty bits.”
Martha hoped that sharing her son’s story and her journey would help other families struggling.
She also hoped that speaking out about the failures that resulted in her son’s death raised awareness in the health sector of a need to do better.
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