The grieving foster parents of a man found dead in his room at a North Shore inpatient clinic claim they warned staff he was suicidal just hours before the 24-year-old died.
They are demanding answers about what went wrong, while preparing to farewell their son.
The young man is one of two male inpatients at Waitematā DHB's He Puna Waiora mental health unit to have died in suspected suicides within four days this week.
The DHB announced the deaths in a statement and said it had launched an independent external review.
Peter Willcox and his wife were yesterday starting the painful process of arranging their foster son's funeral.
Willcox, who contacted the Weekend Herald about the incident, said their son, who they had cared for since he was 1, was born with foetal alcohol syndrome. He had been in and out of the centre for the last three years as a voluntary patient.
The Weekend Herald will not name their son because his birth family were still being informed of the death by police.
On Thursday, Willcox's wife had collected their son from the clinic and taken him out for the afternoon.
The pair had McDonald's then picked up Wilcox after he finished sailing, before dropping their son back about 6.30pm.
It was the last time they would see him alive.
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"It's one of those emotional things when you look back on it," Willcox said last night.
"He wanted to shake my hand and I said, 'No, I need a hug'."
About 8pm Willcox's wife received a phone call from their son "indicating what he wanted for his funeral".
"We contacted the ward and said, 'We believe he is suicidal. We believe he needs to be on watch'."
About 11pm they had a call saying he was dead.
Willcox said their son had enjoyed an overnight visit to their house four days earlier, when he had been "joking and quite happy". They learned of the first patient's suspected suicide as they were preparing to return their son to the unit on Monday.
Asked if their son knew the other man who died, Willcox said: "[The clinic's] like a community. Because of his disability, that was his mate."
They were worried how the first death would affect their son and raised concerns with unit staff.
Willcox said his son had a history of suicidal tendencies and risk factors should have been carefully considered by staff.
"Alarm bells go off. This was a high-risk situation. If nothing else they should have known of his history."
Willcox believed that given the warning signs and concerns raised by family, staff should have put his son on psychological watch.
The inquiry would need to determine what notes were taken by staff and whether concerns were properly communicated, he said.
"There is some question around what has happened here which obviously need to come out in the review.
"In my opinion, he was in the wrong place, being managed in the wrong way."
Willcox said he had emailed Health Minister David Clark several times in the past six months with concerns about his son's care, but felt they had been swept under the carpet.
In a statement, Clark extended his heartfelt sympathies to both families.
"It is important that tragedies such as these are thoroughly investigated. I welcome the DHB's decision to launch an independent expert review. It would not be appropriate to comment further at this stage."
Acting director of the DHB's mental health services, Dr Kevin Cleary, apologised to the two families last night and told the Weekend Herald the organisation extended its "deepest sympathies".
He confirmed the Willcox family had raised concerns with unit staff about their son before he was found dead.
Cleary would not confirm what action staff took in response as this was subject to the independent external review. He said staff were traumatised.
"I'm not going to go into the clinical details. But ... I believe there should never be a suicide in an inpatient mental health unit.
"These families have entrusted their loved ones to our care and it is important that they have answers about any factors contributing to their deaths."
The DHB had already put more staff into the unit and made counsellors available. The review would focus on the unit's functioning, the physical environment, and the care provided.
"Maintaining a high level of public confidence in our care and in our facilities is crucial. We believe this review will identify any factors so we can minimise risks for patients in the future," Cleary said.
The deaths were subject to separate independent external expert reviews and coronial investigations.
The Government's twice-delayed response to the report of its Inquiry into Mental Health and Addiction Services is due shortly before the Budget on May 30.
Among the report's recommendations were urgently implementing a national suicide prevention strategy, implementing a suicide reduction target of 20 per cent, reforming the Mental Health Act and establishing a new Mental Health and Wellbeing Commission.
WHERE TO GET HELP:
Need to talk? 1737 (free call or text 24/7)
• Depression helpline: 0800 111 757
• Kidsline: 0800 543 754
• Lifeline: 0800 543 354
• Rainbow Youth: (09) 376 4155
• Suicide Crisis Helpline: 0508 828 865
• Whatsup: 0800 942 8787
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 firstname.lastname@example.org 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.