The young man took his own life while receiving care at an inpatient mental health unit at North Shore Hospital in May 2019. Photo / Dean Purcell
The young man took his own life while receiving care at an inpatient mental health unit at North Shore Hospital in May 2019. Photo / Dean Purcell
WARNING: This story refers to suicide and self-harm and may be upsetting.
A young man receiving care at a North Shore mental health unit took his own life after a series of failures by health authorities that culminated in a second man committing suicide at the same facility days later.
Nicholas Barthow, 28, was found dead in his room at North Shore Hospital’s He Puna Waiora unit on May 12, 2019.
His friend Tamaki Heke, 24, died four days later at the same unit on the day of Barthow’s funeral after posting a social media message saying: “Rest in peace my bro, sorry I couldn’t be there to save your life the second time.”
Heke’s foster mother had called the unit that evening concerned about his suicide risk, but was told he was in “good care” - before being phoned back hours later to be told he was dead.
The deaths triggered a damning 2020 review which cited poor leadership and staff burnout. It also found patients felt neglected, humiliated and disrespected, resulting in some losing hope and “giving up”, and that the unit’s physical design assisted patients in taking their own lives.
Coroner Alexander Ho recently released findings into Barthow’s death, ruling it was self-inflicted.
He said shortcomings in Barthow’s care likely contributed to his decision that day, and the outcome could have been different had care been more carefully tailored to his condition.
The findings detail Barthow’s tragic upbringing, sad history of mental illness and multiple self-harm attempts from the age of about 10.
He had suffered neglect and possible sexual abuse from his birth parents and was uplifted by child protection services at age 18 months. He had multiple foster care placements before being placed with his adopted family at the age of 3.
Nicholas Barthow received treatment at the He Puna Waiora adult mental health inpatient unit at Takapuna.
He was cognitively, emotionally and physically delayed as a child, and later diagnosed with ADHD, Asperger’s syndrome, dyspraxia and anorexia as an adolescent, as well as borderline personality disorder and post-traumatic stress disorder.
In April 2019, he was taken to hospital after self-harming. A “proximate stressor” was an upcoming court appearance on fraud charges.
“Nicholas blamed his alternate personality ‘Michael’ for the self-harm and criminal behaviour.”
He was voluntarily admitted to He Puna Waiora on April 30, 2019.
The plan was to discharge him after 48 hours, but this was extended due to difficulties identifying a safe place for him to go.
He was assessed as high risk of self-harm and put on 15-minute observations.
On May 10, he was seen trying to harm himself. He told staff ‘Michael’ did not want him to be “here anymore” and was trying to “get rid” of him.
On May 12, Mother’s Day, Barthow attended a family event where he discussed his anxiety about what might happen to him due to his imminent discharge from the unit and the upcoming fraud case.
“His parents said that they would continue to love and support him. His brother described the conversation as challenging.”
Barthow returned to the unit at 8pm and went to bed at 9pm. He was found unresponsive in his room at 10.40pm and could not be revived.
A Waitematā DHB adverse event report identified four main issues with Barthow’s care.
These included a lack of prompt access to personality disorder specialist care; the assessment and management of his risk while an inpatient; insufficient senior clinical roles at the inpatient unit; and a lack of family communication.
Specifically, it found clinical leadership was lacking, with the crisis service and inpatient unit left to care for Barthow due to a lack of specialist community care.
It meant Barthow’s care management “had a short-term focus and did not address his needs beyond respite or accommodation”.
While the coroner said both “systemic and resourcing issues” were identified, it was impossible to ascertain the impact these issues had on Barthow’s decision to end his life.
“However, on the balance of probabilities, I consider it likely that the lack of prompt access to specialised care and the erroneous focus on Nicholas’ accommodation and respite needs rather than on his core risk, in both cases likely exacerbated by the limited staff resourcing available, contributed to Nicholas’ death.
“The outcome may well have been different if more focused care specific to Nicholas’ condition had been provided.”
The coroner noted the 2020 review made a raft of recommendations, which the DHB said were being implemented or already actioned.
These included reviewing the senior clinical structure and staffing volumes; and improving recognition and response to imminent risks, including when safety concerns were raised by families.
Barthow’s family declined to comment on the coroner’s findings.
Te Whatu Ora Waitematā acting clinical director for specialist mental health services, Dr Aram Kim, said Barthow’s death was a tragedy.
“We fully understand the devastating impact it had on his loved ones and the staff who cared for him.”
The organisation accepted the coroner’s findings and extended its sincere condolences and thoughts to everyone involved.
“The patient’s death was fully investigated at the time by an expert independent panel and policy changes were implemented as a result – as acknowledged in the coroner’s report.
“We note the coroner has made no further recommendations.”
Coroner Ho also investigated Heke’s death. In a decision earlier this year, he found that after learning Barthow had died, Heke was “distressed and reported intense urges of self-harm”.
It was likely Heke had “continued to ruminate” about this friend’s suicide after retiring to bed, then made “an impulsive decision to end his life”.
Peter Willcox says staff at the acute mental health unit missed crucial warning signs before his foster son's suspected suicide. Photo / Dean Purcell
Heke’s foster father Peter Willcox said there were similarities in the two cases, both of which highlighted a lack of integration and community support for mental health patients.
He said Barthow’s anxiety about his upcoming court case and imminent discharge should have been red flags for health professionals with regard to his heightened risk.
“They were all risk factors. Somebody should be saying, ‘Where is this guy at? Are we just going to discharge him out into the community and leave him to flounder?’
“We’re just taking these people and dumping them in the community with no support, and that’s where we’re failing so badly.”
Willcox his family had been deeply impacted by the tragedy. And despite multiple reviews, he felt nothing had changed since his son’s death.
Lane Nichols is a senior journalist and deputy head of news based in Auckland. Before joining the Herald in 2012, he spent a decade at Wellington’s Dominion Post and Nelson Mail.
