WARNING: This story deals with suicide and may be distressing.
A young woman who lived most of her life in some form of state care, including 10 years at a mental health facility, told a nurse she wanted to kill herself and detailed what she would use to do it. Shortly after she was given those items and later died. This is Esther's story.
A mental health patient who described to a nurse how she intended to kill herself was minutes later given the items she said she would use to do it.
Esther Osborne died in hospital three days after an incident in a de-escalation unit at Tāwhirimātea, a specialist mental health in-patient facility in Porirua, Wellington.
She never woke up after the incident. She had detailed to a nurse her plans just minutes earlier while they were walking outside the unit on July 1, 2016.
A Coroner's inquest has yet to be held into her death but the Herald has seen a Serious Adverse Event draft report of the review into Osborne's care leading up to the incident.
The Herald is restricted from reporting the method of any suicide and must refer to Osborne's death as a suspected suicide until a Coroner makes a ruling.
Osborne's mother Tasi Huirama wants answers over why her 27-year-old daughter was handed the exact items she said she would use to take her own life.
"I'm so angry. Her sisters are devastated. We were really close. We complained ... but nothing changed."
Jane Stevens, whose son Nicky took his own life in mental health care in 2015, said Huirama had been silenced for too long by a prejudiced system and it was time to be heard.
"That family have been through hell and back," Stevens said.
"She's been carrying this horror for all this time.
"When people are silenced in the way that they are around mental health and suicide ... it takes time for them to get through the trauma and now she has been able to connect with other families and feel a sense of safety and solidarity to speak out."
The review of Osborne's care, dated June 22, 2017, was undertaken by a psychiatrist from another district health board, a mental health nurse and a senior health and disability auditor and cultural consultant.
It said Osborne, known by her family as Ziporah, had a diagnosis of schizophrenia. She was only partially responsive to anti-psychotic treatment, leaving her with chronic residual psychotic symptoms.
She was subject to a compulsory inpatient treatment order under the Mental Health Act at Tāwhirimātea, a regional intensive rehabilitation and extended care service operated by Capital and Coast District Health Board.
Osborne had been at Tāwhirimātea for 10 years. In that time it's understood she was discharged once but readmitted after two weeks.
The review said Osborne was receiving appropriate pharmacological, psychological and socio-cultural interventions at the time of her death, but that two weeks prior she tried to harm herself and often threatened self-harm when she was distressed.
"Family members advised the review team that during the months of March and April 2016 client A [Osborne] had made frequent contact with them and disclosed to them on a number of occasions that she wanted to commit suicide," the review states.
"Family members advised the review team that they had shared their concerns with the unit staff that client A was feeling suicidal."
On the day of the incident, she had become upset following a phone call with a family member, the review stated.
She was overheard by staff complaining that "no one cares for me here" and "I hate all of you".
"She was taken for a walk, during which time she voiced her desire to kill herself, suggesting she might do that by [withheld]."
Osborne was upset and began to cry. She had told her family she wanted to leave the unit.
"... she 'felt tired of all this' ... she 'wanted to kill herself'," the review said.
"A decision was made that she would benefit from some low stimulus time and she returned from her walk and was taken to the de-escalation unit."
Osborne's threats were not told to staff managing the de-escalation unit by the nurse when the pair returned.
Instead that nurse went to get Osborne's medication and when the nurse returned Osborne had already been escorted to the de-escalation area.
There was no evidence of an assessment of Osborne's risks at the time and no plan for de-escalating her distress, the report said.
Capital and Coast DHB observation and engagement procedures state all clients admitted into a de-escalation area must be under minimum observations of five times per hour or not less than every 15 minutes.
But continuous observation must be implemented for patients who had suicidal intent and plan.
"This was not implemented in the care of client A."
In short, Osborne was handed items she had said she would use to kill herself and left alone.
"A review of the paper and electronic copies of client file suggest that critical information in the hour before client A's death was not conveyed to the registered nurse responsible for coordinating the de-escalation area of Tāwhirimātea.
"It is also evident that policies and guidelines regarding the use of de-escalation unit were not being adhered to."
Two staff interviewed for the review outlined concerns about the "institutionalised nature of the culture" of the unit and the focus on institutional routines over the needs of patients.
Huirama said Osborne's whānau lodged numerous complaints over their daughter and sister's care but the review said there was no obvious evidence of them being received or responded to.
"She was in solitary there for quite a while. They locked her up. She was taking 310 tablets a week. She had her birthday there, turned 17," Huirama said.
"We weren't allowed to have birthdays with her or Christmas. She ended up staying in that hospital for 10 years.
"She was crying to get out of there. She ran away a few times. But she got institutionalised."
A spokeswoman for Capital and Coast DHB said because of obligations under the Privacy Act and the Health Information Privacy Code, it was not able to speak publicly about individual cases.
The review said since Osborne's death, a new procedure had been written for the de-escalation unit to address procedural shortfalls that were either unknown or not implemented at the time.
• A review of the culture and practice at Tāwhirimātea with a specific focus on patient-centred care;
• An audit of staff attendance at essential training associated with their role in Te Korowai-Whāriki - the regional forensic mental health provider;
• All de-escalation unit staff to be educated on policies and pathways and a formal record kept of that training;
• All nursing staff within the de-escalation unit to undertake training in acute assessment and formulation of risk;
• The service should investigate the validity of the complaints made by Osborne's whānau and respond to them;
• A review of nursing staff competence in reasonable care and skill and/or possible breaches of the Health and Disability Consumer Rights Code.
Osborne would have turned 30 this Friday.
Where to get help:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
OR IF YOU NEED TO TALK TO SOMEONE ELSE:
• LIFELINE: 0800 543 354 (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633
• NEED TO TALK? Free call or text 1737 (available 24/7)
• KIDSLINE: 0800 543 754 (available 24/7)
• WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757