Warning: This story contains distressing content that involves suicide.
A grieving foster father says staff ignored crucial warning signs before his son's suspected suicide at an acute mental health unit just days after another sudden death.
And though a report has cleared clinicians of blame, Peter Willcox feels it is an attempt to absolve Waitematā District Health Board of responsibility.
Willcox's worried wife Rita phoned staff at North Shore Hospital's He Puna Waiora clinic in May last year warning Tamaki Heke was suicidal, and was told he was receiving good care.
Hours later the family received a call informing them the troubled 24-year-old had been found dead in his room.
Heke's suspected suicide came just four days after a fellow patient at the unit also died suddenly.
The deaths are subject to separate Coronial investigations as well as an independent high level review.
The DHB says it understands the devastating impacts on Heke's loved ones and it has extended an open invitation to meet with the family to discuss the report's findings.
It says the death was fully investigated by an independent expert panel.
Heke's foster family are calling for an overhaul of the mental health system and have lodged a complaint about the care he received with the Health and Disability Commissioner.
The Herald has obtained a copy of the DHB's internal investigation report, which the organisation declined to release.
It sheds light on events leading up to the tragedy and Heke's complicated background, which included being diagnosed with fetal alcohol spectrum disorder (FASD) and a long history of self-harm and suicide attempts.
Despite his foster mother's warning and Heke previously trying to end his life at the unit, the report found his "attempt to die was impulsive and taken without thought for the consequences".
"It is unlikely that a particular action could have prevented TH's death.
"However, addressing the whole system improvement issues may prevent a death in these circumstances from happening again."
Willcox believes staff missed obvious warning signs and ignored the family's pleas to watch over their son.
"Effectively he was stuck in a prison for three years with nothing whatsoever to stimulate him or do.
"It's no wonder that Tamaki was spiralling down.
"Staff are not listening to family members, to people who know these individuals the best. The system's not learning from its mistakes. It just keeps on repeating them."
The report describes Heke as "personable and warm", talented and creative. He taught himself to play piano by studying YouTube videos and developed skill in carving.
Several days before the death, the Willcox family warned staff Heke was distressed by the other patient's suspected suicide and at high risk.
They requested he be kept in ICU for his own safety. The request was declined and Heke was moved back to the open ward, though this was not communicated to the family.
Heke had been an inpatient at the unit for about five months at the time of his death and was considered "like family" by staff. He'd returned to the facility about 6pm that day after being granted leave with his foster parents.
The Weekend Herald reported last year that soon after arriving back, Heke called his family "indicating what he wanted for his funeral".
His foster mother immediately rang unit staff to warn them, asking for him to be placed on watch.
"She was concerned for his safety and was given reassurance that he was receiving good care," the report states.
"Although TH was ruminating on the recent suicide on the unit and his recent relationship break-up, TH remarked to staff that he 'won't do anything tonight'. The clinical notes reflect that staff were aware of these two stressors."
After a meal of fish and chips, Heke remained in his room with the door unlocked on hourly therapeutic observations. He was last seen alive at 9.05pm.
The young man was found unresponsive at 9.40pm. Staff activated an emergency response and tried to resuscitate him for 25 minutes before he was pronounced dead.
His foster parents were informed by phone at 10.35pm.
"They were phoned again at 11.00pm and asked if they wanted to come and see TH before he was transported for autopsy. They declined. The family have expressed upset at this procedure and felt that the police should have been sent to their home with someone from Victim Support."
The review team investigated Heke's troubled background and interviewed staff and family.
It found he frequently talked of suicide, on some occasions telling a nurse "I'm always suicidal".
"Staff were therefore tasked with not simply assessing the presence or absence of suicidal thoughts, but their intensity and TH's intent to act on those thoughts."
Though staff were aware of Heke's feeling about the recent patient death, "there was no acute concern of increased suicidality".
The report also noted a tension between unit staff and Heke's foster family, who believed his FASD disability had been misunderstood by clinicians.
"The family have described an overall view that the 'system' had let their son down throughout his life.
"It is the whānau view that a general lack of knowledge, understanding and training on FASD meant that TH was not treated and supported adequately.
"It also meant that the family felt that they were viewed with some contempt as they voiced their concerns and repeatedly requested more FASD-specific interventions and less medication/psychiatric interventions."
The report found the unit's clinicians could not have prevented Heke's death, but identified "system improvements", in particular around gaps in care for patients with FASD.
It also stressed the importance of family connections to supporting patients, saying clinicians should view families with compassion and understanding.
"There was no sense from any clinicians interviewed that they understood or practised this."
The report recommended new resources and training for staff around FASD, and reviewing protocols for contacting and supporting families after a sudden death.
Heke is one of four mental health patients to die while under compulsory care at Waitematā DHB in two years.
Waitematā DHB Specialist Mental Health and Addiction Services clinical director Murray Patton said the DHB extended its condolences and thoughts to Heke's family, whanau and friends.
The mental health team had worked with Heke and his family over an extended period. His death was fully investigated by an expert panel, independent of the DHB.
"The panel did find a number of contextual factors that have contributed to recommendations for further action. A priority amongst these is the need for the development of services better able to meet the needs of people with fetal alcohol spectrum disorder (FASD).
"The DHB fully accepts and agrees with this as an area for attention, locally and nationally.
Waitematā DHB has raised the need for care and dedicated services for people with FASD with the Ministry of Health. In the absence of these specialised services, DHB treatment plans for people with FASD are tailored to their individual needs from within the range of mental health, community and/or disability support services.
"The DHB offered to meet with the Willcox family to discuss the report but due to the Covid-19 lockdown, this was not possible. There is an open invitation to meet with the family at a time that suits them."
•Waitematā DHB mental health patient died on unescorted leave
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12252791Coroner identifies series of failures after death of young father at Waitematā DHB mental health unit
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12252791Grieving parents say North Shore mental health inpatient unit warned before son's death
Willcox said his family - who had cared for Heke since the age of 1 and commemorated a year since his death on Friday - were still grieving and trying to make sense of what had occurred.
"The last year has been really tough. Dealing with the 'what ifs', how I could have done things better, the loss, the senselessness of it.
"My wife put years and years of effort into Tamaki and to see it flushed down the toilet at the drop of a hat ..."
Willcox said he disputed aspects of the report but was not given the opportunity to review it.
His family were also awaiting the overarching review into the unit, sparked by the two suspected suicides last year, but had not been contacted by the review panel and feared "we won't have a voice".
He felt our mental health system was focused too narrowly on the crisis model, and prescribing drugs instead of psychological interventions.
There was a dangerous element of complacency by clinicians, as demonstrated in his foster son's death, he said.
"They had an individual who was different from their normal clientele. They had a duty of care to get to understand Tamaki and apply appropriate treatments which they didn't do.
"It would be very easy to blame individuals when in reality we should be saying, 'Our health system is broken, how can we fix it?'"
Where to get help:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• The Word
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• CASPER Suicide Prevention
If it is an emergency and you feel like you or someone else is at risk, call 111.