Before the 23-year-old’s body was found on September 8, 2018, Tutai, who had paranoid schizophrenia, was addicted to cannabis and cannabinoids, known as synthetic cannabis, and was under the influence of drugs on 124 of the days during his time at the home in the Hamilton suburb of Hillcrest.
This was against the rules but the main treatment at the support home was talk therapy and medication.
Tutai could have taken part in alcohol and drug counselling but did not engage.
The home, called Waatea and run by Connect - now called Ember - was a level four support home but not one that provided supervision or conducted searches.
Its policy was that residents were free to leave and return to the campus at will and would only be reported missing to police after 24 hours.
On the night before Tutai’s body was discovered at a nearby school, a registered nurse was on “awake” duty, checking the residents in their beds as they slept.
An inquest that opened on Monday in the Hamilton District Court heard the nurse, who has name suppression, made several checks on Tutai but after saying goodnight to the young man about midnight, he didn’t “sight” Tutai again as he should have.
This was because Tutai’s door was locked when the nurse returned at 3am and he thought he could see a shape in the bed. He did not see Tutai at 6am either.
The former relationship general manager Peti Deed, who was only on the job two weeks when Tutai died, said she found out after his death that the nurse had a fulltime job at Waikato Hospital and was working part-time for Ember on a casual contract basis.
Deed was told for the first time at the inquest that the nurse went straight to his shift at Waatea that night from Waikato Hospital, where he had just worked a shift. He was also late.
She reported the nurse to the Nursing Council and he was referred to the Health and Disability Commissioner, who made no adverse comment against Ember for its care of Tutai. The nurse remains registered.
The inquest heard Tutai was selling his food to buy drugs from the “tinny house” a few doors down and that cannabis was a trigger for his psychosis.
Tutai, of Cook Islands Māori descent and a Jehovah’s Witness, grew up in Tokoroa and was the eldest of three children, according to consultant psychiatrist Dr Mohammad Shuaib.
He began using drugs and alcohol as a young teenager and symptoms of mental distress arose after that, including attacking his brother with a golf club, which was out of character.
He was admitted several times to Waikato Hospital’s mental health unit after becoming psychotic and displaying threatening behaviour, but had a history of not taking his medication.
When he did take anti-psychotic medication, his symptoms were relieved but one medication caused myocarditis, inflammation in the heart, and he had to stop it.
Tutai also suffered low mood and reported thoughts of self-harm over the years.
The inquest heard that at Waatea, Tutai was verbally abused at least twice by other residents in front of staff and nothing was done.
Two weeks prior to his death, he suffered a seizure and was “frothing at the mouth” after he and another young resident took drugs. Police were called, but no ambulance.
Deed said there were five reasons why she believed Tutai’s death was not a suicide, including that he could not have managed the way in which he died, which cannot be reported, and that a carload of people turned up too soon after his death to have known without potentially being involved or knowing someone who was.
However, Coroner Matthew Bates pointed out the car arrived at Waatea seven hours after Tutai’s body was found.
When asked whether a resident could be reported missing earlier than 24 hours because of their high and complex needs, Deed agreed this policy could change.
But asked specifically about whether Ember could have done anything differently, she said though the thought haunted her she didn’t believe Tutai could be saved.
“Without sounding conceited, there’s nothing we could have done differently in that regard to save his life.”
Tutai was described as loving music and rugby, and he was incentivised to reduce his illicit drug-taking with tickets to a Chiefs rugby game.
Deed said Tutai often went busking and used earplugs to listen to his favourite music, which was calming.
When Tutai was found about 7am, almost exactly five years ago, there was a heavy undisturbed dew around him and his clothes were damp, indicating he had been there some time.
His earphones were connected to his phone and still playing music, which Deed said broke her heart.
The inquest is set to continue all week with evidence to be heard from the nurse, a pathologist, staff at the care home, police and Tutai’s mother and sister, who were in the back of the court today.
Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.
