Warning: This story contains distressing content.

A patient on unescorted leave from an acute mental health unit is believed to have drowned after entering the ocean in search of Taylor Swift.

A report by Coroner Sarn Herdson has ruled the empathetic and inquisitive young man did not take his own life. Family believe he died accidentally trying to reach his fixation.

Stephen Richard Kapeli, who suffered from bipolar disorder, was a sectioned patient at Waitematā District Health Board's acute mental health unit He Puna Waiora at North Shore Hospital.

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His body was found on Takapuna Beach on April 11, 2017 - a week after he went missing from the inpatient facility while on approved, unescorted leave.

A decision by Coroner Herdson says he received treatment from Waitematā DHB's mental health services as a teenager and young adult.

"Stephen had articulated his beliefs of having special abilities in relation to the computer, having or wanting to have a relationship with the pop star Taylor Swift, and other views, all of which appeared imagined, rather than grounded in reality," the decision says.

He would experience manic and psychotic episodes which his family feared put him at risk of being hurt, including climbing to heights or wanting to be at Takapuna Beach at night in the hope of meeting the US pop star.

US pop star Taylor Swift performs during at Vector Arena in Auckland in 2013. Photo / File
US pop star Taylor Swift performs during at Vector Arena in Auckland in 2013. Photo / File

In 2011, he became unwell while completing a computer course. Kapeli had been using cannabis and synthetic drugs and was spending many hours on the computer, often playing World of Warcraft, a fantasy, interactive online game.

He was admitted to the North Shore mental health unit in July 2012 after scaling Auckland Harbour Bridge and running "laps" at the top in an effort to gain Swift's attention.

He was later discharged into the care of his family, who the coroner noted was supportive, loving and involved in Kapeli's life, and received care through the DHB's community mental health team.

Kapeli remained sectioned under the Mental Health Act for several years, but was discharged in 2016 when his condition improved.

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He continued to receive injections of long-lasting antipsychotic medication but stopped taking the prescription drugs in January 2017, and his condition deteriorated.

Kapeli continued spending long periods on the computer and his fixation returned, the decision says. He also spent a lot of time at the beach, including in bad weather.

The 26-year-old was readmitted to He Puna Waiora in March 2017 to receive compulsory inpatient care, and resumed his medication.

While there, he was granted short periods of unescorted leave.

On April 5, 2017 a court hearing occurred at the hospital ordering that Kapeli remain under inpatient care for further treatment. It's understood he became upset, but later that day he was granted one hour's unescorted leave.

He was checked by nursing staff about 3pm, telling them he was not going to hurt himself and would not go to the beach.

He left the facility about 90 minutes later and did not return.

His parents were alerted and a search began. Police were also notified.

His body was discovered by a woman walking her dog about a week later.

A forensic pathologist found the cause of death was drowning. Toxicology testing found no relevant traces of alcohol or drugs.

Coroner Herdson said Kapeli's disappearance and death were sudden and unexpected for his loved ones.

"His family members were understandably distressed by his death and were also concerned as to how the sequence of events had unfolded."

His mother, Sue Carter, told the coroner she held ongoing concerns.

She felt clinical staff should have alerted the family when her son came off his medication in early 2017.

"She posed the question whether Stephen's privacy [patient privacy] was worth more than his life?"

She believed better planning and even tracking was needed for unescorted patient leave, and said it was important her son's death was not defined as suicide.

"Stephen did not commit suicide and was never suicidal," Carter believed.

"On the day he went missing he was in a happy frame of mind, he would have gone swimming to be with Taylor Swift."

Kapeli is one of four mental health patients to die while under compulsory care at Waitematā DHB in two years, including two suspected suicides within days of each other at He Puna Wairoa last May which are now the subject of an independent review.

Last August the Weekend Herald revealed a DHB report into Kapeli's death had faulted the care he received, leading to policy changes to avoid similar tragedies.

The "significant incident review" report found health staff's decision not to inform Kapeli's parents when he came off his medication "deviated from optimal care".

Stephen Kapeli with his mother Sue Carter. Photo / Supplied
Stephen Kapeli with his mother Sue Carter. Photo / Supplied

"The fact that they did not know had the potential to delay recognition of relapse by his family, and precluded the family from engaging in discussion with SK re the pros and cons of his decision."

The DHB report also found clinicians should have considered Kapeli's previous history, including the manic episode five years earlier, before granting him unescorted leave.

After considering the DHB report, Coroner Herdson said no further recommendations were required.

But she added there was confusion among health staff about whether Kapeli's parents knew he was refusing medication, despite being an adult who was entitled to make independent choices.

She noted the DHB report did not criticise staff's decision to grant Kapeli unescorted leave.

The Coroner agreed with Carter that his death was not deliberate.

The young man's condition had been improving with positive developments in terms of unescorted leave and compliance with medication.

There was no evidence Kapeli had been suicidal or at risk of self-harm.

Coroner Herdson said despite the efforts of family and police, there remained information gaps about Kapeli's death and no witnesses.

She ruled he drowned accidentally on or about the day he went missing after entering the water near Takapuna Beach.

In a statement, Waitematā DHB Specialist Mental Health and Addiction Services clinical director Murray Patton said the DHB remained deeply saddened by Kapeli's death.

"This tragedy has had a deep impact on Mr Kapeli's family and loved ones, as well as our own staff, and we offer our sincerest condolences."

The death was subject to a Waitematā DHB review and coronial investigation.

"Overall, the coroner's report was satisfied with the DHB's extensive review and did not make any formal recommendations or comments. The coroner did make some general observations in relation to issues raised by Mr Kapeli's family, which we fully acknowledge, and have implemented changes and improvements to address these points.

"We will continue to support Mr Kapeli's family in whatever way we can, as well as our own staff who have been affected by this death."

Carter declined to comment on the Coroner's report, but previously told the Herald she held no ill will towards DHB staff.

"I never, never blamed the hospital for what happened and I still don't. I believe they are in an unenviable position dealing with the most vulnerable cases.

"They genuinely cared for Stephen. They may have made mistakes but they all went in there wanting to do the right thing."

Where to get help:

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)
The Word
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.
READ MORE:
Waitematā DHB mental health patient died on unescorted leave
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12252791Coroner identifies series of failures after death of young father at Waitematā DHB mental health unit
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12252791Grieving parents say North Shore mental health inpatient unit warned before son's death