The death of a young man in mental health care is the focus of an inquest which has heard of staff not having the right information to guide decisions. David Fisher writes of a key witness and changing testimony around Jordan Keil’s escape.
When did Jordan Keil escape?
It’s a question without a definite answer at the inquest into the 25-year-old electrician’s death after changing testimony in the witness box from psychiatric assistant John Beazley.
Evidence at the inquest showed Keil’s door was shut over three different observation periods that Beazley had initialled in records as seeing him at the Tiaho Mai secure mental health unit in South Auckland.
Beazley, who acknowledged the forms were sometimes backdated, said initially in a statement he had seen Keil at 7.30pm and then in the witness box changed that timing to just before 8pm.
It was 16 hours later Keil’s mum Debbie Thorpe found her son dead in gardens just five metres from that room on Middlemore hospital grounds.
Beazley’s recollection formed part of a confused sequence of events that changed in the witness box during attempts to pin down the last sighting of Keil on the evening of February 7, 2022.
Coroner Rachael Schmidt-McCleave is hearing evidence of Keil’s descent into psychosis and his eventual death while a compulsory mental health patient. It is for her to rule if Keil’s death was suicide and to make recommendations in the interest of reducing the chance of a similar tragedy.
The inquest at the Auckland District Court has heard of mental health workers missing key information and decisions that would have been made differently.
It has also heard of Keil’s journey to Tiaho Mai after experiencing increasing anxiety in early January 2022.
By the end of the month, he was hearing voices and becoming agitated. On January 31, the day he was admitted to Tiaho Mai, he twice placed himself at risk while speaking of suicide.
Evidence to the inquest heard staff were under pressure and wrestling with Covid-19 mitigation efforts with senior mental health services manager for Counties Manukau, Jeremy Stockton, recalling that summer.
Stockton, who has long worked in Counties Manukau mental health, was not involved in Keil’s care but was drawn into the aftermath when appointed to a senior role in May 2022.
At the time, he said Middlemore Hospital and Tiaho Mai were the safety net for Auckland International Airport arrivals needing Covid-19 managed isolation. The evolution of the new Omicron variant was due any day - “we did not know exactly what to expect but had to anticipate the worst-case scenario”.
“It was also understood at that time that the mortality rate from Covid for people experiencing mental illness was higher than for other populations, potentially almost double.”
Stockton said the pressured situation was compounded by new “information every day” which “kept changing”.
“Decisions were having to be made extremely quickly, and changes were occurring without the benefit of our usual clinical governance oversight.”
He said at the time Tiaho Mai, and other secure mental health units in Auckland, was full.
“We also had a significantly fatigued workforce who had been trying their best to deliver healthcare through the pandemic with the extra stresses that created.”
Evidence of Keil’s time in healthcare came through a review from consultant psychiatrist Kurt Wendelborn, who summarised the medical notes and his own interactions with the young man at Tiaho Mai.
He said Keil - over two sessions - had told him of feeling in low spirits and depressed for a “considerable time”, with a “fragile sense of self-esteem”. For this, Keil had spoken of attempting to reinforce his confidence and manage anxiety through alcohol and recreational drugs, citing MDMA particularly.
Before being admitted, Keil told Wendelborn he was experiencing “irrational thoughts” and was “overreading” situations, believing people were speaking against him and “misinterpreting innocuous conversations and normal workplace banter”.
Wendelborn said those issues escalated significantly to Keil becoming “fearful, distressed and overwrought” and attempting to take his life.
Later, in care, Keil “reflected on just how close he came to suiciding had it not been for the thought of his parents discovering his body and the effect this might have had on them”.
On February 7, the day Keil escaped from the unit and was believed to have taken his life, Wendelborn said he was “pleasant and polite” to nursing staff, “engaging in conversation and raising no management concerns”.
Evidence showed staff at the unit had to check on Keil every 15 minutes. Wendelborn’s notes reported Keil was found to be absent from his room at 8pm “when nursing staff approached it to deliver his dinner”.
The timeframe around that became confused with testimony from Beazley, who was named best psychiatric assistant at the nursing awards that year. In his witness brief to the inquest, he spoke of carrying out three 15-minute checks on Keil up until he was relieved for his dinner break at 7.30pm.
Referring to the 7.30pm sighting, his statement said: “This was the last time I saw Jordan.”
In that statement, Beazley related returning from his dinner break and finding Keil’s door closed with his colleague outside on his mobile phone.
“I looked at [the colleague] and I said: ‘Hey, where’s that fella?’ ‘Aw, he’s having a shower?’
“I said: ‘Bro, you’re supposed to have your eyes on him at all times’,” and was told Keil wanted privacy for a shower so he “allowed him to close the door”.
Beazley’s statement said he went into the room and Keil was not there. He said he discovered a jury-rigged block on the room’s window - a piece of wood to keep it shut - had been prised out to allow the window to open.
But in the witness box, Beazley’s testimony changed as he sought to explain observation notes from that night which showed he checked on Keil at 7.45pm and at 8pm.
In testimony, Beazley said he came back from his break about 7.55pm - and acknowledged the observation sheet showed he had signed saying he saw Keil 10 minutes earlier. And then, under questioning, he acknowledged signing as seeing Keil at 8pm.
When quizzed about the forms, he was asked if they were ever signed “retrospectively”. “We’re not allowed to, but it has been done,” he said.
“So just as I was filling that one out and then I could see him or it would have been like within the minute, going on to 8 o’clock, minute, two minute, so I filled in that next one.”
Beazley said the conversation he recounted in which the door was closed because Keil wanted privacy happened at 8.15pm when he returned with his dinner.
The lawyer acting for Keil’s whānau, barrister Moira Macnab, drew Beazley back to his description of seeing Keil at 7.58pm.
In quizzing Beazley, she provided electronic door records showing Keil’s room was closed from 7.27pm until 8.04pm.
She said: “I put it to you you could not have observed him because the door was closed.” Beazley responded: “Not observed him. So I was sitting there watching him at that time.”
Beazley went on to explain that the door was faulty and would show as closed when it was open. Pushed on whether it was 8.04pm when he saw Keil, he insisted it was 8.15pm when his notes marked the escaped patient as “AWOL”.
Other evidence has heard that Keil’s disappearance was logged by a nurse at 8pm and a senior clinical nursing manager reporting being telephoned at that time and told he was missing.
On discovering Keil was missing, staff alerted police and his parents but believed he was heading home. The inquest has heard they did not check the gardens outside the window that was found open.
Where to get help:
• Lifeline: Call 0800 543 354 or text 4357 (HELP) (available 24/7)
• Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: Call 0800 376 633 or text 234
• What’s Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
• Depression helpline: Call 0800 111 757 or text 4202 (available 24/7)• Helpline: Need to talk? Call or text 1737
• Aoake te Rā (Bereaved by Suicide Service): Call 0800 000053 or referrals@aoake-te-ra.org.nz
If it is an emergency and you feel like you or someone else is at risk, call 111.
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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