Warning: This story deals with suspected suicide and may be upsetting.

The death of Nicky Stevens after he left a Hamilton mental health facility was avoidable, a coroner's inquest has heard.

Consultant psychiatrist Dr Margaret Honeyman criticised the Waikato District Health Board psychiatrist in charge of Nicholas Taiaroa Macpherson Stevens' care in March 2015, saying the doctor missed numerous warning signs in allowing the 21-year-old unescorted leave from the Henry Rongomai Bennett Centre.

The DHB psychiatrist's identity is suppressed.

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Stevens was under a compulsory care order when he left the Waikato Hospital centre on March 9 for a 15-minute cigarette break and never returned.

His body was found in the Waikato River three days later.

Jane Stevens during her evidence into an inquest for the death of her son Nicky Stevens. Photo / Alan Gibson
Jane Stevens during her evidence into an inquest for the death of her son Nicky Stevens. Photo / Alan Gibson

His parents Jane Stevens and Dave Macpherson, a Hamilton city councillor and now a Waikato DHB member, say they implored mental health staff not to let their son out of the medium secure ward 35 unescorted.

Honeyman, an expert witness at the inquest before coroner Wallace Bain, said Stevens was at a higher risk of suicide or self-harm because of a number of factors and should not have been granted unescorted leave.

"This tragic outcome was in my view avoidable," she wrote in a report to police for the inquest.

"He was not safely contained," she said in a brief of evidence before the coroner.

"The records indicate that Mr Stevens was still acutely psychotic. This does not seem to have been factored adequately into his risk assessment."

She listed the risk factors as Stevens being acutely psychotic with a relapse of schizophrenia, that he had active delusions, he told his mother he had failed to drown himself in the Waikato River days earlier, and he told a trainee nurse people had the right to kill themselves.

"Despite what Mr Stevens may have said when he denied any thoughts of suicide, there is compelling evidence that he was reporting things to his mother which he concealed from staff.

"It was therefore unwise to rely on his assurances."

Under questioning from the DHB psychiatrist's counsel, Harry Waalkens, QC, Honeyman rejected that her opinion that Stevens' psychosis was not factored into the leave plan, was speculation.

"I don't think it is speculative because the evidence was there that a decision was made to give him unescorted leave."

She said she was not suggesting the psychiatrist ignored Stevens' clinical notes but that the team did not give them significant weight.

The Henry Rongomai Bennett Centre where Nicky Stevens walked out of unescorted and never returned in March 2015. Photo / Derek Flynn
The Henry Rongomai Bennett Centre where Nicky Stevens walked out of unescorted and never returned in March 2015. Photo / Derek Flynn

Waalkens asked how Honeyman could possibly know what weighting was given because she was not there.

"You've only judged this through the lens of the outcome."

Honeyman said her opinion was based on the clinical notes and information of relevance should be in there.

Waalkens said in the final family meeting with Stevens and staff on March 6, the family did not object to unescorted leave - according to the DHB psychiatrist's evidence.

He suggested Honeyman's opinion was driven by hindsight, but she said Stevens' recent history of attempted suicide was also hindsight and should have been factored into the risk assessment.

Waalkens quoted a 2011 article by a New Zealand psychiatry expert saying it was wrong to use a suicide risk assessment to drive a treatment plan.

But Honeyman disagreed.

"If you're sitting in a clinical situation and you have an individual who is maybe suicidal you have to do a risk assessment."

She said the patient's history and past behaviour must be taken into account.

"I think if you didn't do that your patients would be very much at risk."

Under questioning from lawyer Richard Fowler, QC, for the family, Honeyman said she believed Stevens was not recovered enough from his psychosis to go outside unsupervised.

The family of Nicky Stevens, (from left) father Dave Macpherson, brother Tony Stevens and mother Jane Stevens. Photo / Natalie Akoorie
The family of Nicky Stevens, (from left) father Dave Macpherson, brother Tony Stevens and mother Jane Stevens. Photo / Natalie Akoorie

Fowler also implied during questioning the DHB psychiatrist's evidence that the family did not object to unescorted leave in the March 6 meeting was wrong.

Yesterday the inquest heard from Stevens' mother that he planned his death and undertook a trial run while a patient at HRBC.

Jane Stevens asserted the DHB psychiatrist either did not look at Stevens' clinical notes or ignored them when creating his treatment plan.

Evidence from the DHB psychiatrist will be heard at the High Court at Hamilton later today.

The three-day inquest is set to conclude tomorrow.

Where to get help:

If it is an emergency and you feel like you or someone else is at risk, call 111.

Lifeline: 0800 543 354 (available 24/7) or 09 522 2999 or free text 4357 (HELP)
Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
Youth services: (06) 3555 906
Youthline: 0800 376 633 or free text 234
Kidsline: 0800 543 754 (available 24/7)
Samaritans 0800 726 666
Whatsup: 0800 942 8787 (1pm to 11pm)
Depression helpline: 0800 111 757 (available 24/7)
CASPER Suicide Prevention