"He was in restraints being wheeled through to the High Needs Unit," she said.
"The handover felt like a fight. I was on my own at the nursing station with a doctor arguing with me about whether she would accept Shaun and a nurse that would not listen to me.
"I had no assistance. At one point I thought they were going to refuse his admission."
The facts
According to the summary of facts, on the morning of April 15, 2014, Gray went to the pharmacy to be given his daily medication of methadone.
After not being allowed to take this medication away with him he became agitated and called his care worker.
He then sent a text to his mother. She called the alcohol and drug treatment centre and explained her concerns.
A plan was then made to collect Gray and bring him to the centre. However, when staff picked him up he told them he'd taken a range of barbiturates and injected himself with acid.
They took him straight to hospital where he was refusing treatment and was aggressive toward staff.
He expressed suicidal tendencies and a call was made to keep him in hospital under restraints.
He was transferred to the High Needs Unit in Ward 21 the next day.
While there the nurse who was originally charged with his care did not complete his admission documentation before her shift handover.
There was also some confusion about the prescription of an abnormally high dose of medication to help Gray sleep. His doctor was called and a lower dose was administered.
In actuality, Gray did not consume any of his sleep medication that night.
Later that evening, just before midnight he was found unresponsive in his room.
Ward 21
Gray's care worker, a registered nurse with the Alcohol and Other Drug service, also gave evidence before the inquest today.
She told the court that she visited Gray in the hospital emergency department on April 16 where she asked him if he had any suicidal tendencies, to which he responded "yes," but would not elaborate further.
Gray was then placed under the care of the Mental Health Act and taken to Ward 21's High Needs Unit.
The nurse arrived at the ward and told the court that it was extremely noisy and busy while she attempted to tell staff there about her concerns for Gray's condition.
"I conveyed my concerns about his current mental state, including biting and scratching which is completely out of character for him," she said.
"I had known him for six years and never seen this kind of behaviour from him before."
She said the conversation was difficult due to the noise level and it was hard to discuss Gray's condition, as well as an error on his drug chart which prescribed him a dosage of sleep medication that was well above the maximum.
"I continued to try and talk to the nurse and give verbal handover.
"She appeared very distracted - I asked her at one point 'Are you even listening to me?'.
"I was very frustrated that day. Every time I tried to hand anything over I was met with quite a bit of resistance.
"I've never had an admission like this."
Methadone
Concerns had been raised about the levels of methadone that Gray had been prescribed by his Alcohol and Other Drug treatment doctor, Dr Sarz Maxwell.
It was found that he was receiving nearly three times the amount of a standard dose.
One of the key factors being analysed is whether Gray's high dosage was prescribed appropriately, and whether the reduction of his dosage was managed safely.
One of the considerations Coroner Matthew Bates is dealing with is whether the reduction in his dosage contributed to Gray's suicidal tendencies.
The first witness who was called before the coroner was instructed to conduct a review into Maxwell's prescribing practices in 2013 and found that on average she was prescribing far higher doses than her counterparts in other areas of the country.
"Shaun had been taking opiates for 15 years and had been on methadone treatment since 2004, so would have been highly tolerant to the sedating effects," the witness said.
"But there needs to be adequate safeguards before this kind of prescribing is undertaken," the man, who has name suppression, said.
"I presume that all doctors prescribing in drug clinics are given the national methadone guidelines.
"They would be aware that there is a constraint in policy to a ceiling dose. So a doctor should be observant of that and compliant."
The second witness - whose title and name are also suppressed - commissioned the review into the methadone prescribing practices of Maxwell.
After the review which found she was prescribing the drug at high doses, he met with the doctor and implemented a plan to have all her patients who were receiving a high dose slowly moved to a lower dose.
He also instigated a formal review into her prescribing practices, but Maxwell returned to America before the investigation could be completed.
On questioning, the witness revealed that he was made aware the doctor was also using opioid substitution medication, though he did not disclose its use.
Scope of the inquest
In May last year, Chief Ombudsman Peter Boshier paid a surprise visit to the infamous ward and released a report describing it as one of the worst in the country.
He found that the 24-bed ward was over capacity. Māori were put into seclusion at higher rates and there was urgent repair work needed.
Boshier also found there were a high number of medication errors, young people were often restrained and their access to telephones and leisure activities was limited.
A new $35 million ward was announced by the government several years ago and was due to open this year, however that opening date has been pushed back to at least 2023.
As part of the inquest there are pages of questions that Coroner Bates is seeking to establish answers to in relation to Gray's death.
Among those are whether the cocktail of drugs Gray was prescribed contributed to his suicidal tendencies and why the nurse charged with his care at Ward 21 did not convey his suicide risk in her clinical notes.
Also under scrutiny is the staffing levels at the ward which were found at the time to be sub-optimal as well as the frequency to which Gray was checked on during his brief stint in the ward.
The coroner will try to establish what has changed at the ward since Gray's death.
Specifically, have prescribing practices changed to ensure patients receive the medicines they're supposed to and whether Mid-Central District Health Board has apportioned more staff to ensure high-risk patients are monitored more frequently.
The inquest is set to call a further 23 witnesses over the next few weeks.
