Jak Seth, who had a history of mental health issues, died after escaping from the emergency department at Bay of Islands Hospital in Kawakawa. Photo / Tania Whyte
Jak Seth, who had a history of mental health issues, died after escaping from the emergency department at Bay of Islands Hospital in Kawakawa. Photo / Tania Whyte
A coroner’s inquiry is scrutinising a hospital’s emergency department and mental health protocol after a teen who was experiencing a psychotic episode ran away just hours before he died.
“The next few days are about Jak and it’s important we recognise that. We’re not here to blame anyone but there may be things that come out that won’t sit comfortably with some people,” Coroner Ho said.
Multiple witnesses will give evidence including his parents, psychiatrists, police, doctors and nurses who were all involved in caring for Jak’s mental health before his death.
He had a background of mental health challenges from 2015 to 2018, living alternately between his mother’s home in Ōtorohanga and his father’s home in Kerikeri. By 2018, he was living primarily with his father, David Seth.
His father gave evidence that, in April 2019, he observed a change in his son’s behaviour. He had withdrawn to his bedroom, lost his appetite and began buying drugs online.
“Leading up to his passing we were drifting apart,” he told the court. “He would go to bed earlier and sleep in longer, leading to few opportunities to connect.”
Early one morning in May 2019, he woke to find his son incoherent in the kitchen.
“He was on the floor in the dining room speaking incoherently, shaking his head and he looked unwell.”
Jak’s condition did not improve over the next two hours and he disclosed he had been sniffing petrol. After calling the mental health hotline, his father was advised to contact 111.
Subsequently, Jak was transferred to Bay of Islands Hospital in Kawakawa.
According to his father’s recollection, Jak seemed to be in “a relatively calm mood” during the transfer.
When he contacted the hospital at 2pm for an update and said he was concerned about Jak’s mental health, he was told that, because he had been sniffing, he might have a chest infection.
Seth said the next time contact he had was a brief phone call from a nurse to tell him Jak had escaped and “the consultant said we should not attend”.
Despite that advice, Seth went to the hospital and was told to wait in the lower car park.
After an hour, he went to reception and was met by police who told him Jak had died.
Psychiatrist Dr Arran Kim told the inquest he encountered Jak in December 2017, noting symptoms of low mood and diagnosed a drug-induced psychosis alongside substance abuse in early remission.
He prescribed Olanzapine. He explained that he did not initiate procedures under the Mental Health Act as Jak was not deemed a risk to himself or others at that time.
Coroner Alexander Ho is leading the inquiry at the Whangārei District Court. Photo / Mike Scott
Kim also mentioned drafting a letter to Jak’s general practitioner, outlining the diagnosis while including a provisional remark of consideration for possible emerging schizophrenia.
Dr Deborah Proverbs, of the Northland DHB, faced questions about the mental health strategy she implemented for Jak in February 2019, which aimed to monitor his mental wellbeing.
When asked about who was responsible for overseeing the plan, she replied: “It rested with me.”
Asked further whether she prescribed any medication at that time, Proverbs answered: “He did not express a desire for medication, so I opted for a holistic approach focusing on building supportive relationships.”
Her notes indicated Jak was suffering from a stress disorder and, when one lawyer referred to the plan as “barebones” in detail, she agreed it did not reflect full discussions and “we’re taught not to write too much”.
While Jak was in the hospital’s emergency department, he was monitored by a key nurse, a doctor and a psychiatrist from the mental health unit, all of whom have name suppression.
The doctor told the court that, when Jak was brought in, he was having auditory hallucinations and was occupied with “black holes”.
The doctor phoned Jak’s father to get some background and his diagnosis was that he was psychotic and possibly septic from an infection.
He told the court Jak was reluctant to take an intravenous line and police were called to help.
The doctor put Jak in the open-plan area so he could keep an eye on him. He told the court there was no isolation room available, nor were there staff available to be assigned to him in a private room.
The doctor said he had a meeting with a DHB psychiatrist and the registered nurse on that day and they decided to section Jak under the Mental Health Act.
“It was agreed Jak should be accompanied by police to the Whangārei mental health unit. The only time he got agitated was when he was talking to [the psychiatrist], he looked extremely agitated and that’s when he took off out of the department.
“My plan was to be there when he was sectioned, that would be when I gave him psychiatric medication.”
When asked why Jak was not sedated, the doctor said staff were still unsure of the source of his infection, which could have affected his health, and he did not appear agitated.
“I know there have been quite a lot of comments that he was agitated, but most of the time I saw him he was sitting on his bed, gently rocking, light communications and he was a little apprehensive.”
Jak’s father told the court he was a “smart and intelligent kid” and the family sought recommendations to streamline information between staff and families, simplifying medical jargon, more resources for those dealing with mental health and establishing a clear communications channel between mental health staff and those who require care.
Shannon Pitman is a Whangārei-based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.
