The parents of Nicky Stevens, who took his own life while in the care of Waikato DHB's mental health facility in 2015, will meet the Health Minister this week to discuss damning Coroner's rulings.

The 21-year-old's death was ruled avoidable by the Coroner in the report released to the Herald earlier in December.

Coroner Wallace Bain found Nicholas Taiaroa Macpherson Stevens' death was self-inflicted after he was allowed out of the Henry Rongomau Bennett Centre at Waikato Hospital on March 9, 2015 on unescorted leave, against the express direction of his parents.

In his report following an inquest at the High Court in Hamilton in June, Bain said Nicky's death could have been avoided had the advice of his parents not to allow their son on unescorted leave been adhered to.


After the ruling, Stevens' parents Dave Macpherson and Jane Stevens said they wanted an apology from the Waikato District Health Board and Minister of Health David Clark.

In a statement yesterday they said they were pleased that the Minister of Health had agreed to meet with them - almost four years after their son's death.

"It's not the first time we have tried to meet with the Minister of Health, but previous Minister Jonathon Coleman more than once turned down our request," Macpherson said.

Nicky Stevens was found dead in the Waikato River three days after walking off from the Henry Rongomau Bennett Centre where he was an in-patient. Photo / Supplied
Nicky Stevens was found dead in the Waikato River three days after walking off from the Henry Rongomau Bennett Centre where he was an in-patient. Photo / Supplied

Jane Stevens said, "we want to discuss the Coroner's recent findings that the circumstances surrounding our son's death make it quite clear that the mental health system is in urgent need of being overhauled and significant changes implemented".

"It's very bitter-sweet to have the Coroner confirm that our son's death could have been avoided and that his treatment was well short of what he would have expected."

The family also want to talk about a series of recommendations they submitted to the inquest and the Mental Health Inquiry which they believe will help to prevent this type of tragedy happening again.

Within the coroner report, Coroner Bain directed that submissions made by Nicky's family, including older brother Tony, be considered by the Government Inquiry into Mental Health and Addiction.

They included; the establishment of an independent IPCA type body to investigate health-related complaints, and a funded, independent whanau advocacy service to help families having difficulties in the mental health system.

They also recommended the provision of a safe environment for at-risk patients to smoke on hospital grounds, and a review of current systems to ensure the genuine partnership between mental health services, service users and whanau.

Nicky's only brother Tony, will accompany his parents to meet the minister.

He said he "wants the government to publicly acknowledge the grief and suffering experienced by many families like us who have to face another Christmas without their loved ones because of the years of neglect and underfunding of our mental health system".

Timeline of events March 9, 2015


Nicholas Taiaroa Macpherson Stevens goes on first unescorted leave returning at 8.53am.

9am: Multidisciplinary meeting to discuss Nicky's treatment. Psychiatrist responsible not informed Nicky breached leave conditions on March 8. Agreed plan of two unescorted leaves per day.

9.15am: He requests escorted leave and it is denied. Allowed to leave between 9.18am and 9.27am.

10.19am: Nicky is escorted to the dairy across the road returning about 10.40am.

11am: He requests leave again and was denied. CCTV captures him leaving the ward anyway between 11am and 11.08am unescorted.

12.29pm: Nicky goes on unescorted leave. He is caught on CCTV kneeling in the foyer with his arms around his torso, swaying, but at least one staff member walks by, ignoring him.

12.45pm: When Nicky fails to return a psychiatric assistant tells his nurse.

1.15pm: Psychiatric assistant notifies Nicky's nurse again of the breach.

1.30pm: Nicky's friends arrive and ask for him.

1.57pm: Another nurse goes to look for Nicky.

2pm: Nicky's nurse rings Stevens to say her son is missing.

2.20pm: Stevens rings his flat but Nicky is not there.

2.30pm: Stevens rings the DHB in distress and speaks to the ward manager. The manager tells Stevens police are doing everything they can to find Nicky despite the fact Nicky has not been reported missing to police.

2.38pm: Nicky's nurse rings police northern communications centre, not through 111, and reports Nicky missing. The nurse gives a conflicting account of Nicky's risk of harm and no police are assigned to a search.

2.40pm: Stevens races to the Waikato River in Hamilton and finds no searchers.

4pm: Hospital security begin a search.

1am: A Henry Rongomau Bennett Centre staff member notices a fax reporting Nicky missing to police has not gone through properly. The report is also incomplete.

March 11, 2015: Police begin search for Nicky.

March 12, 2015: Nicky's body is found in the Waikato River in Hamilton.


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 111.

If you need to talk to someone, the following free helplines operate 24/7:

LIFELINE: 0800 543 354
NEED TO TALK? Call or text 1737
SAMARITANS: 0800 726 666
YOUTHLINE: 0800 376 633 or text 234

There are lots of places to get support. For others, click here.​