There was disagreement around the future care of a Wellington man who died of a suspected suicide in acute care.
Coroner Peter Ryan began an inquest into Samuel Fischer's death on Tuesday.
The 34-year-old died in the care of Capital & Coast DHB (CCDHB) while in a secure mental health unit in April 2015.
A framed picture of Fischer sits next to his mother Lyn Copland at the inquest in the Wellington District Court.
The care leading up to Fischer's death was discussed in evidence on Wednesday morning.
A nurse – whose name is suppressed – said a few days before the incident a meeting was held to discuss Fischer's future and the option of sending him to a regional rehabilitation unit.
The nurse said Fischer was "enthusiastic" about the idea at first.
"He had artistic tendencies that he was hoping to be able to further while in rehab and saw that as an opportunity to continue that."
The nurse said Fischer's mother, Lyn Copland, and advocate disagreed and wanted him to return home to live with Copland.
Members of the care team believed that going back to his mother's house wasn't an option.
He said the disagreement caused "distress to Sam because he felt thwarted".
Another nurse, who also attended the meeting, said Fischer was agitated and didn't feel like his needs were being listened to, which caused him to leave the room.
Fischer had an extensive mental health history extending back to the 1990s. He was diagnosed with bipolar disorder complicated by cannabis and alcohol substance abuse.
Police had also been aware of seven incidents of self-harm or suicide attempts between 2000 and 2010.
He was admitted voluntarily to the crisis mental health team in early 2015 and kept in the acute inpatient unit under the Mental Health Act as a patient for about 10 weeks.
By this time Fischer was having "significant delusions", including contacting Air New Zealand, believing a plane had been hijacked.
Fischer absconded twice from the unit, the second time he was found walking down a highway in Marlborough.
He also obtained a credit card and racked up $20,000 in debt.
A nurse who worked closely with Fischer said during his time at the in-patient unit he was a "caring, intelligent, thoughtful and talented man".
On the afternoon of April 17, 2015, it was reported Fischer had been banging his head on a wall in a bathroom.
The nurse said he presented as "perplexed and confused" and after taking some medicine – his mental state had stabilised, and he was engaging.
When his mood improved, he wanted some quiet time to play guitar in his room.
A nurse left him at 5.20pm and said they would come back and check at 6pm.
At that time Fischer was found in his room unresponsive and was transferred to hospital. He died three days later.
Copland, took a case against the DHB over her son's death.
In a 2017 Givealittle fundraising page, Copland said she "can't get her boy back, but she's determined to expose the mental health system's flaws".
"Sam Fischer died in the one place he should have been safe - Wellington Hospital's secure mental health unit.
"I want Sam's legacy to be improving the mental health system for others."
The DHB reached a settlement with Copland in April 2018.
In a statement, they said Sam was well liked by staff who knew and cared for him, and they have all felt his loss.
"The key recommendations from the serious adverse event review have been actioned."
A CCDHB staff member who gave evidence at the inquest said the treatment of Fischer "did not fall below expected standards".
They said the DHB has accepted all findings and recommendations in previous reports into the death and responded accordingly.
One report said the risk of attempted suicide should've been a more prominent feature in Fischer's management at the time and documentation surrounding risk management should've been better.
The DHB accepted risk documentation wasn't adequate.
The staff member said there had been a significant improvement and immediacy in day-by-day records since, with a client pathway and shared digital client records shared between the three DHBs in the region.
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Samaritans 0800 726 666
• If it is an emergency and you feel like you or someone else is at risk, call 111.