WARNING: This article deals with suicide and may be upsetting.
Nurses for a Wellington man believed to have killed himself in a secure hospital mental health unit insist they wouldn't have done anything differently.
Coroner Peter Ryan this week began an inquest into the cause of death of 34-year-old Samuel Fischer, who died in the care of Capital & Coast DHB (CCDHB) in April 2015.
Fischer died in Wellington Hospital's ICU after an incident in his room, believed to be a suspected suicide.
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.
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 three months.
Police were aware of seven incidents of Fischer harming or attempting suicide between 2000 and 2010.
They included overdosing on drugs and mentioning he had "had enough".
In the inquest today, one nurse said Fischer did not show clinical signs of depression, and there was no indication he was about to commit suicide.
He said Fischer had problems with aggression, not depression, and while he had low moods at time this did not indicate he wanted to kill himself.
"The signs weren't there," he said, adding Fischer often talked about the future.
"I think that people were doing everything they could to provide the best care possible for Sam."
Another nurse who discovered Fischer dying in his room also said she would not change how she handled the situation.
She first checked to see if Fischer was conscious and saw he was not breathing, and pressed her duress alarm.
But the nurse said she couldn't hear the alarm going off and believed it was not alerting other staff, so ran out briefly to call for assistance. She then returned and began chest compressions.
Letizia Ord, lawyer for Fischer's mother Lyn Copland, questioned why the nurse left Fischer alone to call for help, and why she didn't immediately begin chest compressions.
The nurse said she started first aid within 30 seconds of finding Fischer, and did not believe she should or could have done anything differently.
"I needed assistance and that was what I had to do first," she said.
On the day of his death in April 2015, it was reported Fischer had been banging his head on a wall in a bathroom.
His mood appeared to be low and a nurse spent time reassuring and assessing him.
Fischer said "he was tired of it all and wanted it to be over". 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.
• 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.