Warning: This story deals with suspected suicide and may be upsetting.
The father of Nicky Stevens has told of the anger he felt when it took three days to be informed his son had made a suicide attempt that required emergency surgery and admittance to a mental health facility.
Because of the delay in alerting Dave Macpherson and Nicky's mother Jane Stevens, Macpherson escalated his concern to the top ranks of Waikato District Health Board.
This was just weeks before the 21-year-old man left the medium-security ward 35 at the Henry Rongomai Bennett Centre unescorted on March 9, and never returned.
His body was found in the Waikato River three days later on March 12.
"My son's death, while a sectioned patient of the Waikato DHB, was a train-wreck waiting to happen," Macpherson said to a coroner's inquest.
"I had early concerns about the way his treatment overall was being handled, and these concerns grew with almost every day of the three weeks he was a patient at the hospital."
The inquest has heard that Macpherson and Stevens implored centre staff not to permit unescorted leave to their delusional son, who was suffering from a psychotic episode.
But the psychiatrist in charge of Nicky's care, who cannot be identified, claims the parents did not raise any objection when unsupervised leave was reinstated just one day after it was revoked.
However, in an email to staff at 3.28pm on the day his son went missing, Macpherson wrote the family had repeatedly opposed unescorted leave - as recently as March 6.
The email, produced as an exhibit, also said Stevens has rung Nicky's psychiatrist on March 9 not knowing her son had gone Awol, and reiterated her concern only to be told the leave was being increased to three 15-minute breaks a day.
Macpherson was critical of the DHB's handling of his son's care during questioning from Richard Fowler, QC, who is acting for the family.
He was also critical of how long it took mental health staff to report Nicky missing and for police to begin a search.
Nicky went on unescorted leave at 12.30pm that Monday and did not return at 12.45pm as required.
He was later seen on CCTV going in and out of the centre until 1.08pm when he can be seen wandering off into bushes.
Two separate timelines, including one supplied by police, show Nicky's dedicated nurse was told at 12.45pm he had not returned but no action was taken.
This fact has been disputed with the Herald by the lawyer acting for the DHB, Paul White, who claims the nurse was not alerted until 1.20pm.
CCTV footage also showed a staff member walk past Nicky as he knelt, swaying in the centre foyer that afternoon, ignoring him.
Nicky's psychiatrist was alerted at 1.30pm he was off the ward and Stevens was alerted to her son's disappearance at 2pm.
She raced to the Waikato River and found no one searching for her son, despite having been told police were doing all they could to find him.
Police did not begin a search for two days.
The inquest heard today that a couple approached Macpherson two weeks after his son died, saying they passed someone they believed was Nicky on a footpath near the city centre on March 10, the day after he wandered off.
Macpherson said he was shocked by their claims and directed them to the police.
Under questioning from Harry Waalkens, QC, acting for the psychiatrist, Macpherson said his son's illness was getting worse and the family was against any unsupervised leave.
"The attempts to harm himself, the aliens, the chain smoking were getting worse at that time."
The inquest heard the unescorted leave was part of a plan to soon discharge Nicky back to community mental health services, but Macpherson said his son was not ready to be discharged.
On the day before he disappeared, Nicky went Awol, returning from a 15-minute smoke break 30 minutes late - but that information was not told to Nicky's psychiatrist at a meeting the next morning.
At yesterday's hearing the psychiatrist said they would have "absolutely" revisited Nicky's leave had they been alerted to his breach of the conditions on March 8.
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 or 09 5222 999 within Auckland (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633 ,free text 234 or email email@example.com or online chat.
• 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
• SAMARITANS – 0800 726 666.