A roll call of shame at one of the country's highest-profile mental health facilities has prompted the families of some patients, whose lives ended tragically, to call for action.
But a district health board says severe mental illness has an 8 per cent death rate which even the highest levels of care cannot prevent.
A Weekend Herald investigation has uncovered 18 notable incidents linked to the Henry Rongomau Bennett Centre [HRBC] at Waikato Hospital, spanning two decades.
• Mental health unit that housed Nicky Stevens before he disappeared was short-staffed, nurses claim
• Police discover body of missing Waikato DHB mental health inpatient
• Mental health patient locked in solitary confinement for 23 days
They include escapes, suicides or suspected suicides, murders, and one former patient who was fatally shot by police.
Now four families have written to Prime Minister Jacinda Ardern and Minister of Health David Clark. They want:
• An urgent, external investigation into the safety and quality of Waikato DHB mental health services;
• A separate and independent national complaints body to investigate serious events quickly and effectively;
• A nationwide support and advocacy service to help patients and families navigate the system including at coronial inquests.
"Our whānau are deeply concerned at the ongoing risks of harm or death to vulnerable patients due to the continuing failure of the Waikato DHB to provide safe and high-quality care both in the community and in its inpatient facilities," the letter said.
"These preventable tragedies are happening too often as the consequence of families' knowledge and concerns being ignored by mental health providers."
The letter is signed by Jane Stevens, Dave Macpherson, Genevieve Simpson, Ray Thomassen and Rosalind Case.
Stevens and Macpherson's son Nicky Stevens died by suicide in March 2015 after being allowed out on unescorted leave against his parents' advice.
Simpson's brother Vaughan Te Moananui died less than two months after Nicky when he was fatally shot by the police.
Thomassen's son Rhys was an inpatient when he disappeared from an escorted walking group and was found dead in Hamilton in November last year.
Case's nephew Matthew Prichard-Case was missing for a month from the centre after disappearing on January 23.
He has since been found and returned but not before his clinical psychologist aunt made a complaint to the Health and Disability Commissioner [HDC].
Former Labour MP Sue Moroney, whose sister Catherine Harris took her own life inside the HRBC in 2001, said she was alarmed at the ongoing deaths.
Moroney said her father specifically asked staff to keep a close watch over his daughter a day before she died, but that request was not heeded.
"They didn't take due care and they didn't listen to warnings from family."
When Nicky Stevens died, Moroney said her family felt let down because it was another case of whānau not being listened to.
Coroner Wallace Bain found Nicky's death was avoidable and that the treatment he received fell well short of what he and his parents would have expected.
"Our experience told us it's the family members who know that person best and they can tell when it really is a crisis," Moroney said.
"The issues are systemic. But the families are made to feel like it's just their person."
The Government recently announced a new $100 million facility to replace the centre, which Moroney said was not enough to address the issues.
"The problems that we faced were a combination of a lack of staffing, lack of appropriate staffing 24/7, lack of communication with families and listening to what families were saying, as well as the design of the building."
Stevens said she was gutted at what she believed were recurring themes.
"Rhys' story is so similar to Nicky's and it's the same issues now that were happening with Sue's sister in 2001.
"I'm losing patience because people are continuing to die. People are being let down by the failure of mental health services to support them properly and keep them safe."
However, the DHB said a 2016 review of the service found it had made significant improvements since 2009.
It said there had been a reduction in incidents resulting in patient harm since 2012 but that if a patient did not return from leave the DHB immediately alerted police and family.
"The DHB acknowledges there is risk associated with leave, as there is risk to restricting patients for extended periods.
"The goal of acute treatment is to prepare patients for their return to the community. It
is not good clinical practice towards supporting recovery for a patient to remain restricted to an acute mental health facility for weeks or months."
The DHB said it could only communicate with designated next-of-kin with the permission of patients.
"Nominated next-of-kin are invited to join in the planning of each patient's care and to discuss any proposed changes or release of patients.
"In the case of any serious event, families are always invited to conference with senior staff and participate in the review process."
The DHB warned about "misreporting" of leave gone wrong and said such negative press could deter mentally unwell people from seeking help.
Ministry of Health deputy director of mental health and addiction Robyn Shearer said patient leave was carefully assessed so that risks were appropriately managed.
"Waikato DHB deals with some of the most complex cases and there are a number of difficult decisions which need to be made on a daily basis to ensure the highest level of care is provided in the least restrictive environment."
She said the Government had accepted a recommendation from its inquiry into mental health and addiction to establish an independent commission but that it would not investigate incidents. That would still be done by the HDC.
A review of investigations into suicides would also be undertaken to ensure the most responsive and supportive system for families was in place, she said.
Henry Rongomau Bennett Centre roll call of shame
March 4, 1999, Shane Holland: The 18-year-old died in a secure room at the HRBC while under observation as a suicide risk. Holland had been transferred to the facility from Waikeria Prison where he was serving two and a half years for stabbing three police officers at Waihi Beach.
June 7, 1999, Paul Probestle and Karl Franklin: Probestle, 36, stomped on Franklin's head in the younger man's room at the HRBC after claiming his fellow patient wanted to baptise him. Franklin, 22, died in Tauranga Hospital on July 3 of his injuries. The DHB defended its forensic unit as secure and said nobody had ever left the inpatient forensic area who wasn't allowed to since the centre opened in December 1997.
June 11, 2000, David Richard Edwards: The homeless Hamilton man's body was found badly decomposed in the Waikato River at Huntly on June 22, 2000. He had been missing since leaving the HRBC on June 11. The 34-year-old had a history of mental illness and had failed to appear in Wellington District Court on a trespass charge.
September 24, 2001, Catherine Harris: Harris died inside the HRBC after staff weaned her off long-term medication for chronic depression. It was her first suicide attempt, after less than three weeks in DHB care including in a residential facility. The 45-year-old's death was ruled unpreventable by a coroner but a day before her death Harris' father visited his eldest child and was shocked to discover she was agitated, frightened and had rapidly deteriorated. He requested staff keep close watch of her.
March 29, 2006, Un-named: A 41-year-old man reportedly died of natural causes inside the HRBC after four nights there. He had been charged with attacking his elderly mother in her Rotorua home earlier that week.
January 19, 2010, Christine Morris: Bludgeoned her neighbour to death with a hammer after scaling a two-metre high fence at the Henry Rongomau Bennett Centre. Morris had already climbed over the fence before and had told mental health workers she wanted to kill 53-year-old Diane White. Staff were told not to follow Morris because she was a voluntary patient. She was later jailed for life.
November 25, 2011, Claire Watson: Scaled a courtyard wall and was found later that morning dead on Collins Rd. She was not reported missing by staff until 21 minutes after police were called to her death. It was the fourth attempt on her life in two months, but the first as a patient at the centre. At her inquest four years later Coroner Garry Evans found Watson should have been continuously observed, that steps to reduce her risk were not taken until after she escaped and that staff should ensure patients were prevented from leaving without permission. The DHB said it had already implemented the recommendations.
November 30, 2014, Karl Foster Police took Foster to the HRBC twice in two days after reports he was about to attempt suicide. Each time he was released the next morning only to return to the public spot again. On the last time police arrived seconds too late to stop him. An advocate wrote to then board chairman Bob Simcock in March 2015 stating Foster's family were concerned he was not properly assessed and should not have been released after two suicide attempts in 24 hours. Simcock wrote back saying he could not discuss the case with a third party but that the Mental Health and Addictions Service was reviewing the death and wanted to "remain engaged with the family" because they were important "stakeholders" whose feedback would help shape potential improvements in the service.
March 12, 2015, Nicky Stevens The 21-year-old's body was found in the Waikato River three days after he left the centre on unescorted leave, an action his parents expressly asked staff not to allow. Coroner Wallace Bain found Stevens' death was avoidable and that his treatment fell short of what he and his parents would have expected. Bain added that the circumstances surrounding Stevens' death made it clear that New Zealand's mental health system was in urgent need of being overhauled and significant changes implemented.
April 6, 2015, Morgan Hamiora-Smith and Benjamin Manuel: Used a kitchen utensil to break an electronic lock before scaling a two-metre high fence at the forensic unit. They were reported to be violent and not approached. A relative of the two men, aged in their 20s, handed them into police in Thames two days later.
May 2, 2015, Vaughan Te Moananui: The 33-year-old father-of-two was fatally shot at his sister's home in Thames after he pointed a gun at police. Te Moananui struggled with paranoid schizophrenia and was released from the HRBC 13 months before his death, against his whānau's wishes. An inquest found Te Moananui's follow-up care lacking. His sister and her two children witnessed the shooting.
July 6, 2016, Talia Kelly: The 24-year-old was an inpatient at HRBC when she was granted unsupervised leave to go for a walk. She was found dead on the banks of the Waikato River a day later. Kelly suffered from post traumatic stress disorder and had been in and out of the centre over a two year period prior to her death.
October 4, 2016, Ross Bremner: Bremner's mental health was being overseen by the HRBC when he murdered his mother Clare and critically injured father Keith at their home in Ōtorohanga. Bremner went on to kill couple Mona Tuwhangai and Maurice O'Donnell in their home at Kinohaku. He also died in a suspected suicide that day. The DHB has not released a review of Bremner's care citing the family's request for privacy and an inquest has yet to be held.
May 22, 2018, John Comer: The long-time service user at HRBC was found dead in the Waikato River on July 19. He was last seen at his Hamilton home by flatmates two months earlier and had been reported missing. The 34-year-old's cause of death was ruled inconclusive by a coroner.
August 25, 2019, Un-named: A man seen falling into the Waikato River, sparking an unsuccessful search by police, was confirmed as a patient of the HRBC on approved unescorted leave, who did not return that morning.
November 11, 2019, Rhys Thomassen: The 24-year-old was on escorted leave with a group when he escaped and was found dead the next day under a bridge in Hamilton. Leave was approved despite Thomassen having written a note making it clear he would run away again. The DHB and police were investigating his death.
January 23, 2020, Matthew Prichard-Case: An in-patient at HRBC Prichard-Case disappeared from the facility and was only found a month later. His family have complained to the Health and Disability Commissioner, the Prime Minister and Minister of Health. Their specific concerns include a lack of engagement and communication with family and the repeated allocated of unescorted leave even after he had gone missing several times in the past.