Coroner David Robinson yesterday stressed that his inquiry – which was scheduled to last two weeks – was not to address "quality-of-care" issues or apportion blame.
His function, he said, was to determine Ross Taylor's cause of death, circumstances of death and to possibly make recommendations that could assist in avoiding repeat scenarios.
The court heard he had died on the night of March 21, 2013, and former friends and flatmates spoke about his erratic behaviour leading up to that point.
Taylor's parents Corinda and Sid spoke about a boy who was "confident, chatty, friendly and happy" through his childhood.
His father described him as having a sharp sense of humour, someone who enjoyed being out in nature.
Corinda Taylor – who founded the Life Matters Suicide Prevention Trust after the tragedy - spoke of Ross showing early prowess as an athlete: skiing, skating, surfing, kick-boxing, golf; able to trounce her at squash by the time he was attending intermediate.
She told the court she only saw a change in him after his first concussion as a teenager.
There were changes in mood, behaviour, social activities, sleep, "easily confused with normal changes of adolescence", she said.
The delays in holding the hearing had repeatedly traumatised Corinda Taylor and she said she had gone on reliving the last week of her son's life.
"I feel his pain and I feel guilt, that I missed the most important signs in my own boy. I blame myself I couldn't keep Ross safe," she said.
After experiencing his first psychotic episode, Ross Taylor was admitted to Wakari Hospital where he was medicated and discharged.
But the family believed he was relapsing at the time of his death.
She hoped his legacy would mean lives would be saved in future.
Sid Taylor said he was similarly upset with what had happened.
He added, however: "I bear no ill will to anybody, I simply miss my boy. I loved him with all my heart. This has left a huge hole in my life."
Ross Taylor's former flatmate, whose name is suppressed, said his behaviour through 2013 became increasingly bizarre.
The witness said his friend was sporadically using drugs and alcohol, and on one occasion put an LSD tab in his eye.
However, Taylor was sober when he drew a series of pictures.
"They just looked like scribbles," the flatmate said. "There was no substance to the pictures but he would talk as if there was great meaning."
He told others he was convinced there was a microchip in his brain through which his parents could control his thoughts.
Friends tried to distract Taylor with surfing and golf, and at times they said he seemed improved.
On other occasions, though, he would talk about "different dimensions and parallel universes".
The aim of the inquest was to determine a range of issues including:
- Was Ross Taylor suffering a relapse of psychosis (December 2012-March 2013)?
- Was a suicide-risk assessment carried out in March 2013 adequate?
- Should he have been involuntarily committed to a facility during the final weeks of life?
- Was the reintroduction of anti-psychotic medication intended?
- Would reintroduction of the drugs have reduced the risk to Ross Taylor?
- Should mental-health-patient records be maintained in electronic format to allow clinicians ready access?
- Did the Southern DHB's perception of his parents inhibit communication?
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
Lifeline: 0800 543 354 or text HELP to 4357
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.
