A young father at "chronic risk" of self-harming took his own life while under compulsory mental health care after a series of failures by health staff.
He is the fourth mental health patient to die while under compulsory care at Waitematā District Health Board in just two years, including two suspected suicides within days of each other at a North Shore unit last May.
And while the board acknowledges failings, it says changes have been implemented to improve patient safety and prevent further tragedies.
The man's grieving mother, Margaret Lees, is now racked with guilt, having admitted her son to West Auckland's Waiatarau acute mental health unit because she feared he was suicidal, and believing he would be safe.
Lees' lawyer has suggested laying a police complaint to determine if staff at the facility could face criminal charges of neglect.
"I trusted the system," Lees told the Herald.
"I wanted to admit my son because I feared he was going to take his own life.
"It wasn't an easy decision. It wasn't made lightly.
"I did expect a lot more than what I got."
Ruarangi Waitai James McIntyre, 30, was found dead in his room at 7.15am on May 27, 2018.
A coroner's report obtained by the Herald found McIntyre died after staff failed to carry out regular 15-minute checks while he was being held in the facility's intensive care unit.
The failure "provided him with a significant window of opportunity in which to take his own life", Coroner J.P. Ryan found.
A Significant Incident Review report into the suicide, also obtained by the Herald, identified other failures.
• Staff left McIntyre with "potentially dangerous items";
• The coroner found there was only an "informal DHB process" for determining whether such items should be left with patients in the ICU.
• Staff found a concerning item in McIntyre's room two days before his death but this was not communicated to his treatment team. The information could have alerted clinicians to heightened risk.
• Mandatory 15-minute "therapeutic observations" were ad hoc, with staff checking at random intervals - at times over an hour apart. This was labelled a "significant departure from expected standards of practice".
The DHB report details McIntyre's troubled background. He suffered sexual abuse as a child, had turned to drug abuse and self-harming in later life, and experienced psychotic episodes and seizures.
Though an addict, McIntyre wanted to get clean and had been due to start a medically assisted detox programme at the time of his death.
He had also spent time behind bars and faced a serious police charge which was later quashed.
The father of three was admitted to Waitākere Hospital on May 22, 2018 after being found in a semi-conscious state by his partner at their Glen Eden home. He had been using synthetic drugs daily, became agitated, was restrained by police and put into sedation.
A consultant psychiatrist at the unit who interviewed McIntyre during his admission noted: "He was a young man with a tragic childhood, related to various traumas... He had issues with self-harm, and was a danger to himself."
McIntyre was granted four hours' leave the day before he died. He returned to the unit at 6.15pm and told staff he wanted to spend the night at home with his partner. The request was denied and he became agitated and upset.
He was given medication, transferred to ICU and was later described as "settled and calm".
About 3.20am on May 27 he asked to watch television. The request was again denied. He became upset and returned to his room where he was heard making loud noises.
Though McIntyre was supposed to be on regular 15-minute watches, the last recorded observation was at 5am. An hourly check at 6am was the last time he was seen alive, the coroner's report says.
A staff member who had just come on duty discovered McIntyre unresponsive in his room at 7.15am. Paramedics pronounced him dead at 7.40am.
During subsequent interviews, staff said they removed the concerning item from his room and discussed it with colleagues, though "no other staff acknowledged knowing about its existence".
The coroner ruled the "lethality of the situation" had not been properly communicated to McIntyre's treatment team.
He was searched when he returned from leave, with "nil found" according to records.
However two staff members admitted noticing a potentially dangerous item, which McIntyre was allowed to keep.
"The staff could not give a definitive reason why they did not take it off him. [They discussed] it was an item that could be easily used for the purpose of self-harm."
McIntyre used the item to take his own life less than 12 hours later.
A letter to Lees from her lawyer Emma Priest advised she could make a formal police complaint, asking them to investigate whether any individual was criminally responsible for her son's death by way of negligence.
"It seems plain to me that accountability is the aspect lacking in the investigation and reports."
Lees, who works with intellectually disabled people, told the Herald she had trusted health staff to look after her troubled son.
"I had professionals around me. He was clinically medicated."
She now regretted her decision to admit him into compulsory care and believed a lack of supervision cost her son's life.
Murray Patton, the DHB's acting clinical director, Specialist Mental Health and Addiction Services, said staff remained deeply saddened by the death.
"This tragedy has had a profound impact on Mr McIntyre's family, friends and whānau – as well as our own staff and the wider community, and we offer our sincerest condolences.
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"The Coroner's Report identified some issues pertaining to our procedures at the time of Mr McIntyre's death which we fully acknowledge and accept were not to the high standard that we normally expect of ourselves."
The DHB participated in two reviews into the tragedy and had implemented changes and improvements to prevent similar failures.
"Other system-wide changes are also in place to improve patient safety and maintain a high level of public confidence in our mental health care facilities.
"We will continue to support Mr McIntyre's family in whatever way we can, as well as our own staff who have been affected by this sudden death."
• Lifeline : 0800 543 354 (available 24/7)
• Suicide Crisis Helpline : 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services : (06) 3555 906
• 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
• CASPER Suicide Prevention
If it is an emergency and you feel like you or someone else is at risk, call 111.