The inquest into the death of Jordan Keil has heard how key health workers did not have critical information. It heard testimony of Keil’s escape from a fast-moving car on the Southern Motorway. David Fisher reports.
A nurse’s nerve-racking testimony about a mental health patient who climbed out of a car on Auckland’s motorway emerged among evidence of knowledge gaps that affected his care, an inquest in Auckland has heard.
The Tiaho Mai mental health nurse spoke of having to suddenly slow and stop after Jordan Ihaia Keanu Keil bailed out of the back seat of the car she was driving from Auckland City Hospital to the Tiaho Mai secure mental health unit, where he was found dead a week later.
The inquest into Keil’s death has heard how his mother, Debbie Thorpe, found Keil in the garden 16 hours after he had escaped the Middlemore Hospital mental health unit, five metres from the broken window through which he escaped.
Events leading to Keil’s death in February 2022 were detailed in the Auckland District Court before Coroner Rachael Schmidt-McCleave and in the presence of the 25-year-old’s grieving family and friends.
The inquest had already heard how Keil was taken to Auckland City Hospital by Thorpe with concerns over her son’s paranoia and delusions, and how he escaped his mother’s custody as they left, having been told he would need to be cared for at home.
Hours later, police found Keil standing on a bridge talking about suicide and returned him to Auckland City Hospital, where he was committed through the Mental Health Act to the Tiaho Mai mental health unit.
The inquest heard that Tiaho Mai nurses Reema Mala and Fia Brunt arrived to collect Keil for a journey that quickly went awry when he broke free again.
While driving on the Southern Motorway, Keil is believed to have climbed through the car window, escaping with a bloodied body and heading to the nearby Sylvia Park mall carpark, where he spent eight hours overnight, threatening to jump.
In her testimony, Mala conceded policy breaches and briefing failures before Keil’s escape from the car she was driving along the motorway.
She described being on an “extremely busy” shift when asked by colleague Fia Brunt to help collect a sedated-looking Keil from Auckland City Hospital. “He seemed to be happy to come with us.”
Mala said she was the driver, had “minimal information” about Keil and expected Brunt to take the clinical lead. As a result, she said she was surprised when Brunt – whose role was to focus on the patient – got into the passenger seat next to her rather than into the back with Keil.
She said Keil’s demeanour was such that the nurses comfortably chatted with him while travelling the Southern Motorway.
At one stage, Mala said Keil asked to have the window down for air. Her evidence included stating the window was up and locked shut until that point – a claim contrary to Thorpe’s evidence that it was half-down as the car left the hospital.
“Fia and I agreed to put the window down about halfway. When we got to the Mt Wellington overbridge, the first thing I knew that something was wrong was when the seatbelt alert went off, indicating that Jordan’s seatbelt had been undone.”
The lawyer assisting the coroner, Wendy Aldred, KC, said Brunt’s evidence was that Keil went out the half-open window of the car, questioning Mala as to whether that was possible given he was 185cm tall and over 90kg.
Mala said she “couldn’t see what was happening at the back” because she was focused on bringing the car to a safe stop.
By the time it was safe to exit the car, she said, Keil was gone. Earlier testimony has heard how Keil then spent eight hours threatening to jump from the Sylvia Park carpark.
Mala conceded it was a breach of policy to have the window down and, in hindsight, “we shouldn’t have put the window down”. It was also a breach of policy not to have a nurse in the back seat with him, she said.
“But at that time he was engaging and complied with us, and it was thought that he could not get out of it, given his size and the amount it was open, and I never thought this incident would occur.”
Aldred quizzed Mala about escort training and the policy document, leading to the nurse saying insufficient regard was given to the task when assigning her and Brunt, that they weren’t properly briefed on the job and should have been told he had not long been brought from a bridge where he was threatening suicide.
Mala said the pair should also have been told he was a runaway risk, and if they had known, “the risk would have increased and I would have questioned the suitability of transportation”.
Later, under questioning, Mala told the coroner she would have expected to have been quizzed afterwards about the incident, but was not. She also said she did not fill out an incident form explaining what had happened.
Tiaho Mai’s clinical nurse manager, Jordan Scanlan, testified about gaps in the knowledge he had around Keil’s pathway into the unit. Scanlan, whose job it was to oversee nursing and support staff at the unit, was on duty the night Keil was expected to be admitted, but he did not turn up.
When Scanlon returned to work several days later, he was told about the escape from the car but not about Keil’s eight hours of threatening to jump from the shopping mall carpark or police recovering him from a bridge where he had threatened suicide.
Scanlan said it was information that should have been passed on.
While it was not Scanlon’s decision to make, he said that had he known about the earlier incidents, he would not have wanted Keil moved from the high dependency unit – the “highest level of care” – to the room from which he escaped.
He said that at the time, he didn’t have any concern but “didn’t know about the aspects of his history”. Also, he said he had not had a chance to meet Keil despite trying to do so and finding he was medicated and asleep.
Scanlon said the missing knowledge was also a factor in the AWOL (absent without leave form) form used to notify police and others of a missing patient. He said it rated Keil’s risk factor at “Category B medium risk” rather than “A”, the higher level.
The form was filled in by a nurse after consultation with him, but neither was aware that it was outdated and was replaced with a “Missing Person Causing Concern” report.
Mustafa Mahmood Al-Mansey was the clinical charge nurse who decided to move Keil from his high-risk room to the less secure room from which he escaped. He told the inquest he would not have made that decision if he had known Keil was a serious escape risk.
He said the decision to move Keil was made when a patient arrived at Tiaho Mai who needed a high level of care and observation. He said it led to consideration as to the patients who could be moved to a low dependency room to free up higher-dependency beds.
Al-Mansey, who admitted Keil to the unit, said he was aware of the previous suicide attempts that preceded the young man’s arrival at Tiaho Mai.
Looking back, he said he was wrong to have moved Keil. He also said he should have consulted the Situation, Background, Assessment, Recommendation record (known as SBar) that was used to keep track of patients.
If he had looked at the SBar, he said, he would have had information that would have led to a different decision. Other testimony to the inquest said the SBar was not often consulted by nursing staff and that information was often cut-and-pasted into it.
The health staff who testified expressed their sorrow and shock at Keil’s death. Al-Mansey did so with an apology, standing and directly addressing Keil’s whānau: “I have never been a father, but I have siblings and I have parents and I can feel how hard this can be.”
He told them he had wished for an opportunity to apologise to them personally, and then said: “I am deeply sorry, and this is coming from the bottom of my heart.”
David Fisher is based in Northland and has worked as a journalist for more than 30 years, winning multiple journalism awards, including being twice named Reporter of the Year and being selected as one of a small number of Wolfson Press Fellows to Wolfson College, Cambridge. He joined the Herald in 2004.
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