Sean Kessels died in November 2023. His death has been referred to the Coroner as a suspected suicide. His mother speaks about her long fight to get him help and his death.
Sean Kessels’ mother is devastated by a “disappointing” coroner’s report and delayed review of his care.
Kessels, 26, struggled with severe mental health issues and died by suicide in November 2023.
He was under Te Whatu Ora care at the time.
The health agency reviewed Kessels’ case but failed to share that with his family.
WARNING: This story deals with suicide and self-harm. Please see below for help and crisis information.
But shesays that a “disappointing” coroner’s report and a “too little too late” review of his care by Te Whatu Ora that was “disgustingly false and inaccurate” has left her devastated.
Kessels, 26, died at his father’s home on November 6, 2023.
“I was trying to get help - the crisis team, everything,” she said.
The next day he messaged: “It’s worse.”
“I rang and told his dad to keep an eye on him ... I was trying to ring and get help … his mental health support team were not returning my calls," Logan said.
“I found out ... that before he died, Sean had been trying to ring and get help too.”
Kessels’ death was referred to Coroner Tracey Fitzgibbon.
Logan hoped she would take an in-depth look to determine if anything could have changed the tragic trajectory of her son’s last day.
She asked the coroner to look at the phone calls she and her son made the day he died and the responses.
Coroner Fitzgibbon decided an inquest was not necessary, that she had the information she needed to determine Kessels’ cause of death.
She released her findings to Logan in February, in which she did not address the grieving mother’s concerns that calls for help went unanswered.
Based on information provided to her, including from police and Te Whatu Ora, the coroner ruled Kessels died by suicide.
But her report does not canvas whether anything could have been done to prevent his death.
She said: “His last engagement with mental health services was on 12 October ... He was not experiencing delusions, and there were no other abnormal thoughts.
“Sean was experiencing intrusive thoughts about hurting himself and other people. They were transient in nature and not associated with suicidal plans or intentions.
“There was no indication that Sean was a risk to himself during this meeting.”
Logan was “shocked” when she received the findings.
“I was hoping for an inquiry into the team Sean had and their response to not being in touch, not ringing back, not helping. There was none of that.
“I was quite shocked when it first came through. I read it and my first thought was, this is just another sweep over.”
Sean Kessels' family are traumatised by his death.
Last month, the Herald contacted Te Whatu Ora seeking information about any contact Kessels had with mental health staff on the day he died - including text messages, calls and emails - and what response was given to him.
Information on action taken after Kessels’ death - investigations, reviews or reports - was also requested.
The next day, Logan was contacted by the clinical head of the Counties Manukau mental healthcare team, Simon Judkins.
It was the first she had heard from any Te Whatu Ora representatives since the week her son died.
“The apology means nothing to me, too little too late and only because (the Herald) got in touch.”
After multiple requests, they emailed her the finding.
“I combed over the file, including email correspondences and associated documentation over HCC and clinical portal. I can see that due diligence has been completed,” said the report writer.
“I cannot see any conspicuous oversights; the follow-up actions were appropriate to the clinical needs of Sean, corroborated by documentation. Interaction with both the family and Sean was conducted appropriately.”
The report also stated that there were “no early warning signs” before Kessels died.
Sean Kessels loved his family - but kept much of his mental health struggle from them.
The report made no mention of any calls for help from Kessels or his mother in the days leading up to his death.
The Herald pushed Te Whatu Ora further on any calls received.
“Through the learning review we are looking to investigate the issue of communications further and have reached out to the family, including Sean’s mother, to do this directly,” Te Whatu Ora Counties Manukau clinical director Dr Ian Soosay said.
He would not answer specific questions about Kessels’ case.
“While the learning review is ongoing, it would be inappropriate to comment further,” he said.
“We acknowledge that we could have done more to engage with Sean’s family, and we are deeply sorry that this has caused additional distress.
“We hope the process going forward will help the family better understand what happened and improve services in the future.
“I extend my heartfelt condolences to Sean’s family for their loss. We recognise that Sean’s death has had, and continues to have, a profound and long-lasting impact for all those who loved him.”
Logan said the review contained incorrect information.
“This is absolute rubbish. Every appointment that was made by us was because Sean was having delusional thoughts. I rang for every single appointment he had and I attended them so know exactly what Sean said,” she said.
“What were the wraparound services? There were none. This is absolute bullshit and lies … the review is disgustingly false and inaccurate.
“The report is so contradictory. It says he has thoughts of hurting himself and others - but then says he posed no risk?
“It definitely hasn’t helped my feeling of how Sean meant nothing to them, to get these details wrong is just another piece of trauma for me to deal with.”
Logan is reluctant to engage further with Te Whatu Ora.
She is considering her next steps, including a complaint to the Health and Disability Commissioner.
“I’ve tried to focus on what I’m doing now, rather than what I can do to change things. I thought that the coroner would have done a better job, and she hasn’t so now I’ve got to make the decision - am I going to fight?” she said.
Logan said she would continue to speak about her son’s death in the hope she could raise awareness and help other families.
“I still go every week and see him at the cemetery, and I still cry every single day - but I’m more private now.
“I just act as normal as I can for those around me … but I’m still traumatised. I’m traumatised from seeing him in a body bag, traumatised about what he did, traumatised from reading about that night in the coroner’s report.
Anna Leask is a senior journalist specialising in crime and justice issues. She joined the Herald in 2008 and has worked as a journalist for 18 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz
