The mother of a man believed to have killed himself in a secure mental health unit has given a harrowing account of her son's numerous suicide attempts, starting in his teenage years.
She also claimed the Crisis Assessment and Treatment Team (CATT) refused to help him on occasions, including during psychotic episodes.
Lyn Copland sat in the witness box in the Wellington District Court this morning surrounded by framed photos of her son, Samuel Fischer, a pair of sneakers, and an old jersey draped across a row of folders.
Photos of Fischer were taped around the room, and to the outside of the courtroom door, with the words "Samuel's tragic & preventable death" scrawled on them in ballpoint pen.
Samuel Fischer's mother walks out of inquest after head-banging incident questioned
Advocate calls for coroner to recuse himself from suicide inquest
Nurses in inquest for Wellington man Samuel Fischer say they wouldn't have done things differently
Future care of Wellington man discussed a few days before suspected suicide
The coronial inquest into Fischer's death began last year, but ran overtime and had to be put off until today. There are three witnesses still to give evidence, including Copland.
Fischer, 34, died in the care of Capital & Coast DHB (CCDHB) in April 2015.
He had an extensive mental health history extending back to the 1990s. He was diagnosed with bipolar disorder complicated by cannabis and alcohol substance abuse.
Copland said Fischer was hospitalised more than once for alcohol-related illness while he was still in school, and said he would swap his lunch money for cannabis.
She believed his mental health began deteriorating at the age of 15 when her marriage to Fischer's father broke up, and Fischer's father moved to the UK.
Copland told the court CATT refused to come to his aid on some occasions, including after psychotic episodes where Fischer told her he needed to burn their house down to protect her from the Mongrel Mob, said he was the prophet Elijah, and showed her an email to Air New Zealand saying there would be a plane hijacking from Wellington to Auckland.
She said she then had to drive him 40km down the motorway to the hospital herself as he screamed, grabbed for the wheel, and tried to touch other cars.
He was admitted voluntarily to the crisis mental health team in early 2015 and kept in the acute inpatient unit under the Mental Health Act as a patient for three months.
During that time he managed to "abscond" more than once, and was able to apply for a credit card and collect $20,000 in debt.
This followed an incident in a previous hospital admission, where he applied for a credit card and collected $15,000 in debt.
"The stress of this debt, which Sam should not have been able to incur while so unwell in hospital, added to subsequent feelings of low mood and played an important role in his death," Copland said.
She also criticised staff for allowing him to have items which he could use to harm himself. For example, his shoes still had shoelaces in them when he died, which she said was "not protocol".
She said suicide attempts while Fischer was in the unit were not correctly documented and passed on to other staff.
Copland criticised the documentation by one of the nurses in the unit, saying she breached standards in a number of ways, "or Sam would have been alive today".
The nurse, who has interim name suppression, failed to carry out a safety check in Sam's room, she said.
"I don't think he died because of his mental illness, I think he died because of all the things that accumulated from being locked up for the whole summer."
Coroner Peter Ryan asked Copland whether she believed Fischer's actions weren't a suicide attempt, but were instead a "protest" to draw attention to the issues he had with his care.
"Samuel probably was aware when the next observation was going to take place. He must have done what he did quite close to that time, because he was able to be resuscitated," he said.
But Copland disagreed, saying Fischer had decided enough was enough, and that suicide was, in his mind, the only way out.
Two reports have found risk documentation surrounding Fischer's care was not adequate and that has been accepted by CCDHB.
The inquest continues this week.
Where to get help:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
Or if you need to talk to someone else:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youthline: 0800 376 633
• Need to talk? Free call or text 1737 (available 24/7)
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Samaritans 0800 726 666
• Rural Support Trust: 0800 787 254.