Warning: This article discusses suicide and could be distressing for some people.
A failure by North Shore mental health staff to carry out 10-minute observation checks on a high-risk patient provided a "window of opportunity" for him to take his own life.
Donald Charles Morey, 71, was found unresponsive in a bathroom on a secure mental health ward for elderly patients at North Shore Hospital on October 10, 2017.
A coroner's report has highlighted a series of failures in Morey's care. Waitematā DHB admits "issues with our care and our facilities contributed to his death".
Morey's grieving daughters say they are resigned to the outcome. They are "finding peace" but still miss their father every single day.
"He was fit and healthy in every other way," Kelly Wilson told the Herald.
"He could still be here had it not been for those mistakes."
Coroner Debra Bell has ruled that Morey committed suicide following a period of severe depression linked to the death of his wife in 2014, a recent relationship breakup and stress over the sale of his house.
The decision was released last year but has never been reported.
Bell faults DHB staff for failing to maintain appropriate checks on Morey, which "provided him with a significant window of opportunity in which to take his life".
"It is not possible to say with any degree of certainty that if Mr Morey's observations had either remained at 1:1, or the I0-minute observation performed, this tragic outcome may have been avoided, nevertheless an opportunity was lost."
Less than a year earlier, 30-year-old father Ruarangi Waitai James McIntyre was found dead in his room while under compulsory mental health care at a secure unit at West Auckland.
Staff failed to carry out regular 15-minute checks, which another coroner ruled "provided him with a significant window of opportunity in which to take his own life".
And a damning review into two suicides in four days at a secure adult mental health unit at Takapuna in May 2019 cited poor leadership and staff burnout, suggesting the building's physical design assisted patients to self-harm.
The foster family of one of the victims, Tamaki Heke, warned unit staff he was suicidal just hours before he was found dead.
In the latest case, Morey - a retired plumber from Snells Beach - was admitted to a mental health ward at North Shore Hospital on September 19, 2017. He had a history of depression and had attempted suicide in 1993.
Morey was initially admitted on a voluntary basis with constant 1:1 observations due to his high level of anxiety and suicidal ideation. He was later sectioned under the Mental Health Act due to his level of risk.
The coroner's finding says Morey found it difficult living on the ward as there were people with a range of serious mental health conditions, other than depression.
His daughters Wilson and Deborah Hussey said he went downhill after being admitted and they'd questioned whether it was the right environment for him.
"Mr Morey struggled to see why he had to remain an inpatient, as he did not see himself as 'crazy'," the coroner wrote.
Morey told clinicians he'd had suicidal thoughts in recent months but was "too scared" to act - "it's too horrifying to think of the nothingness".
Clinicians met with Morey's family on October 2, 2017. It was agreed that his depression had worsened and he was placed under a compulsory treatment order.
A few days later Wilson told staff her father's delusions had become more overt, including talking about cameras spying on him.
Morey appeared "guarded, suspicious and paranoid". He told staff "people should be allowed to die when they choose to", and "you guys make it really hard to kill yourself in here".
Morey appeared to improve between October 6 and 9, when it was concluded he had "turned a corner" in his treatment and was on his way to recovery.
On October 10, the day of Morey's death, a nurse suggested reducing Morey's observations from 1:1 to every 10 minutes.
He had denied any thoughts of self-harm and said he found it "intrusive" to have someone with him at all times. A clinical psychologist agreed to change Morey's observation status.
The coroner's decision says that afternoon several 10-minute observation checks were missed - at 2.50pm, 3pm and 3.50pm.
The alarm was raised at 3.58pm when Morey was found unresponsive in a bathroom.
A significant incident review report carried out by the DHB, obtained by the Herald, says staff mistakenly called for security, resulting in a 10-minute delay before a resuscitation team was alerted and dispatched.
The report said the unit was "not fit for purpose" as an acute inpatient facility and had multiple points that could physically assist someone to take their own life.
It noted clinicians had not documented their decision to cease constant monitoring of Morey or referenced any risk assessment.
It was "common" for nurses to miss 10 minute observation checks when busy, which had been a "significant factor" in other significant incident review reports carried out by the DHB.
The Coroner said it was regrettable that more suitable placements for Morey's needs had not been available.
"I am still concerned that it has been more than three years since Mr Morey's death and there is no alternate facility for patients in a similar position to be housed by WDHB."
She urged the DHB to prioritise a new acute psychogeriatric facility, and to urgently address the current building's physical element which could be used by patients to self-harm.
Wilson told the Herald she accepted the findings but was frustrated the system hadn't changed.
"I feel sorry for the staff. They do their best and these people aren't in these jobs because of the money. They are genuinely caring people. But the Government hasn't provided the right facilities or proper staffing."
Hussey said her father's death was preventable and the family was still angry.
"All of it's pretty poor really. The fact that they left dad unchecked when they did. If they hadn't it might have been a very different outcome."
Waitematā DHB said it extended its deepest condolences to Morey's family.
"We continue to be profoundly sorry for their loss. We accepted the Coroner's findings, and recognise that issues with our care and our facilities contributed to his death."
The DHB had completed internal and external investigations into the tragedy resulting in significant changes to therapeutic observation practices and facilities.
"The coroner's review and findings released last year resulted in no further recommendations being made due to the changes we had already put in place.
"While the actions undertaken came too late for Mr Morey, these steps have created a safer environment for our patients. We recognise the hurt Mr Morey's family continues to feel and we are happy to meet with them again at any stage to discuss their concerns."
Where to get help:
• Lifeline: 0800
543 354 (available 24/7)
• target='_blank'>Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO)
(available 24/7)
• Youthline:
0800 376 633 or text 234 (available 24/7)
• target='_blank'>Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942
8787 (12pm to 11pm)
• Depression
helpline: 0800 111 757 or text 4202 (available 24/7)
• Anxiety
helpline: 0800 269 4389 (0800 ANXIETY) (available 24/7)
• Rainbow Youth: (09)
376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.
Rapana Heretini, a father of two, died on May 29 at Waikato Hospital.