Issac Tuatai was released from prison without his schizophrenia medication. He took his own life soon after. Photo / File
WARNING: this story is about suicide and self-harm.
A schizophrenic man whose mental health had been deteriorating in prison was released without any of his medication or a treatment plan and took his own life day - passing away two days after his 21st birthday.
A Coroner has identified “systemic failures” from the Department of Corrections in the lead-up to Issac Robert Parua-nae Tuatai’s death - including his probation officer not being told about his state or lack of meds, resulting in a lack of urgency to have him assessed by a specialist mental health team.
Had things been done differently the troubled young father-of-one may still be alive.
Corrections admit their “systems and processes” let Tuatai down and they have “unreservedly” apologised.
Tuatai was found in a critical condition on December 14 2020 and rushed to Middlemore Hospital where he was put on life support.
He spent four days in intensive care before it was confirmed to his whanau that he was brain dead.
The machines keeping Tuatai alive were withdrawn and he died early on December 18.
He had turned 21 on December 16.
Tuatai’s death was referred to Coroner Alison Mills and in March she formally ruled it a suicide.
Her findings were released to the Herald and outlined a number of failures by Corrections in the lead-up to Tuatai’s fatal self-harming.
“Issac was released from prison on at least two occasions without his medication for schizophrenia,” she said.
“I am particularly concerned about his release on 28 September 2020. The evidence shows that Issac’s mental health was deteriorating.
“Five days before his release he was assessed by the psychiatrist. He was struggling with hearing multiple voices and background noises and his medication was increased.
“Being released at short notice meant that Issac was not able to participate in a transition programme and he was released to no fixed address and without his medication or appropriate referrals.”
Coroner Mills said she could not criticise individual probation officers who had worked with Tuatai and raised concerns about his “lack of progress with his release conditions, his transience, and his general non-compliance with his conditions.
“On release, Issac failed to attend any medical appointments or assessments despite being directed to by his probation officer.
“However there appears to have been a systemic failure in that the probation officers do not appear to have been advised of the deterioration in his mental health prior to his release nor were they aware that he was released without his medication.
“There therefore does not appear to be any urgency attached to Issac’s need to be assessed by the community mental health team or of the need to ensure he had his medication.
“Overall, there does not appear to have been any plan made to ensure he was assessed and to ensure he received his medication, which, given his history and his recent deterioration in prison should have been considered a priority.”
Coroner Mills said Tuatai was born in Auckland and raised mainly in Northland.
His parents separated when he was young and he spent time living with both of them.
“Issac told his probation officer that he had a very unsettled upbringing,” said the Coroner.
He claimed he was exposed to people using methamphetamine and domestic violence.
Tuatai started smoking cannabis when he was 15 - when he first started to get into trouble with the police.
“From about 2017 life for Issac appears to have spiralled into a tragic cycle of drug and alcohol addiction, psychosis, and criminality,” said the Coroner.
“He shuffled between the criminal justice system and the mental health and addiction services.
“In 2019 Issac was diagnosed with schizophrenia with the differential diagnosis of a drug-induced psychosis with ongoing alcohol, cannabis and methamphetamine abuse.
“He became involved in a gang. By 2020 Issac had amassed 23 criminal convictions, including 10 for relatively serious violence, including aggravated robbery and assault on the person in a family relationship.
“Issac had two known previous suicide attempts during this time.”
In May 2020 Tuatai was sentenced to six months’ home detention and the court heard he had acknowledged the role methamphetamine and alcohol played in his offending.
“He also admitted his gang associates and antisocial support had also played a part in his offending,” said Coroner Mills.
“He expressed a desire to disassociate himself from the gang, to get employment and to start supporting his daughter.”
Tuatai was allowed to serve his sentence at the home of a relative who was also on home detention but was doing well and “was managing to progress in a more positive direction”.
He was released from custody without his medication and the first night he ran away to his grandmother’s house after having panic attacks.
Once his medication arrived he “settled down” but was drinking and using cannabis with his relative.
On May 15 2020 the relative committed suicide.
Tuatai was in the house at the time and his family later said the death had “a significant negative effect on Issac who felt responsible” and “blamed himself for not being able to help”.
His probation officer tried to help and support him working closely with local police and mental health team” but he was hauled back to prison when he was caught drinking at the relative’s tangi - a breach of his conditions.
Soon after his home detention sentence was cancelled and he was jailed for five months.
“Issac’s prison records note that he was at risk of suicide and record that on many occasions he was ‘feeling low enough to take his own life, doesn’t cope when not taking his meds for schizophrenia becomes depressed and has anxiety attacks’,’ Coroner Mills said.
“It also recorded that he “needs to be tested for alcohol and drugs regularly as this affects his antipsychotic medication and functioning which in turn risks that he will disengage from mental health services.”
In September 2020 Tuatai’s mental health was deteriorating and prison records stated he had “described hearing multiple voices inside his head that sometimes argue or hold conversations”.
As a result, he was seen by a psychiatrist and his medication was increased.
“He denied that any of the voices were commanding him to harm himself or others,” said Coroner Mills.
“While he could not articulate the actual content of these voices, there was ‘lots of negative stuff’.”
Just days later, due to a recalculation of his prison sentence, Tuatai was released at short notice - without participating in any reintegration programmes.
He was released to “no fixed address” in Northland and ordered to check in with his probation officer weekly and attend any programmes as directed.
Tuatai failed to attend appointments with a psychiatrist and counsellor and was given a written warning when he missed a weekly check-in.
In October 2020 he reported randomly to a probation office in South Auckland and said he had moved to live with his mother nearby.
On December 3 a duty probation officer noted his case had not been formally transferred to Auckland and spoke with his mother
She said he “appeared low and had not been taking his medication”.
On December 9 Tuatai reported to the South Auckland probation officer and advised he was travelling back to Northland for a funeral.
His next check-in was arranged for Northland and it was noted that Tuatai “had seen a different probation officer every time he reported and was not making any progress with his rehabilitation conditions”.
Tuatai then decided not to travel to the funeral and stayed behind at his mother’s house, with an aunty asked to keep an eye on him.
On December 14 she went to drop off food to Tuatai and found him with severe injuries and near death.
Coroner Mills received a number of drug and alcohol and mental health reports from the Northland DHB, Counties Manukau DHB and the Department of Corrections.
“All of these reports confirm that Issac had a history of drug and alcohol abuse and mental health difficulties,” she said.
The reports revealed that before Tuatai was diagnosed with schizophrenia he had been “hearing voices” constantly for at least 18 months.
“These voices were negative and derogatory. His mother reported that Issac had been having suicidal thoughts as a way to escape the voices,” the Coroner said.
“The voices have been telling Issac to hurt himself and at times others. He felt controlled by the voices and believed some of the thoughts were not his own.
“He had previously stopped smoking cannabis and methamphetamine, but the voices had continued. He reported feeling hopeless.. and had hurt himself by cutting his arm to get rid of the voices but still continued to hear them.”
After his diagnosis, he was prescribed antipsychotic medication which he was supposed to take each night and up to three times daily to help with agitation and distress when required.
“At the time, Issac was assessed as being a moderate risk to himself with thoughts of self-harm and suicide but no clear intent,” said Coroner Mills.
“Initially he agreed to take medication and be followed up by the services however he subsequently did not engage and declined medication and further input.”
From then on, Tuatai seemed to pinball between services - including police and Corrections when he offended - until his death.
“I cannot determine precisely what triggered Issac to make the decision to end his life in December 2020. Tragically he appears to have reached this decision privately and did not alert his whānau or his probation officers to his true level of distress nor provide them with the opportunity to try and seek help for him,” the Coroner said,
“Issac was a highly vulnerable young man... (he) had on at least two previous occasions attempted suicide.
“He had been without his medication for about two-and-a-half months prior to his death and his treating clinicians had noted that he did not cope well without his medication.
“Research also suggests that people recently released from prison, such as Issac have a heightened risk of death soon after release.”
Corrections Health Services advised the Coroner that it was unaware of Tuatai’s release as his sentence had been recalculated.
“Corrections’ Health Services acknowledge that there is no documented evidence that any planning had gone into Issac’s release,” said Coroner Mills.
“He was not seen by any medical professional prior to his release, no review of his care was undertaken, nor discharge letter populated.
“The Department of Corrections’ health care pathway policy that was in force at the time of Isaac’s release required that these steps be undertaken.
“The Health Centre manager at Northland Regional Corrections Facility also stated that if they had been aware of his planned release, they would have provided him with at least one week’s medication plus a one-month prescription to take to a local pharmacy.”
Coroner Mills was advised there were “a number of reasons why Corrections Health Services may not be advised of a prisoner’s release.
“The quality and practice manager acknowledged that the failure to notify Corrections’ Health Services of unexpected releases was a national issue that required improvement,” she said.
“I was advised that this issue would be raised in early 2022 with the Department of Corrections joint health/custody monthly meeting.
“The aim was to develop a standardised process to ensure health services are notified of all releases as soon as practicable.”
Corrections Health Services had also reviewed - or was still reviewing - and strengthened the release process including implementing the provision of up to one month’s supply of medication or a prescription to those who need it.
“For an unplanned release, or a release at short notice, a Patient Health Release information document is to be completed,” said Coroner Mills.
“In light of the ongoing review and the changes to the policy, I do not consider there are any specific recommendations that I can usefully make, that would address my concerns about Issac’s release without medication,” she said.
However, she did make a recommendation that Corrections undertake a significant internal review to see if it could make improvements around how probation services monitor offenders after release.
“Issac was a highly vulnerable young man. He had drifted between health care services and in and out of custody,” she said.
“He had a recent history of suicidal ideation in prison, had experienced the recent loss of a close relative through suicide, which was known to the Department of Corrections, and had reported deteriorating mental health five days before his release.
“He was released early without his medication or any ongoing plan… His decision to move to Auckland meant that he reported to different duty probation officers who did not know his history and did not have a relationship with him.
“While I cannot say with certainty that the outcome would have been different, the failings I have identified provide an opportunity to learn and to improve services.
“I therefore recommend that the Corrections and the probation service undertake an internal review of the services provided to Issac to identify how the services could be improved.”
Corrections health acting deputy chief executive Kerry-Leigh Dougall said the agency was “committed to learning from the findings” of the Coroner’s report “so we can prevent this happening in the future”.
“We would like to express our heartfelt sympathies to the man’s loved ones. I can only imagine the grief they must be continuing to feel,” she said.
“We have a duty of care to people in prison, which we take extremely seriously. On this occasion, the systems and processes we had in place let this man down, and for that, we unreservedly apologise.”
Dougall confirmed Corrections had “made a number of changes and improvements since this tragic death”.
“And we have continued this work to improve our health services since we provided information to the Coroner,” she said.
“We have a Suicide Advisory Board where we have been discussing how we can work to improve services in the community, and information available to our Community Corrections staff, around managing suicide risk.
“In addition to this, we have made a number of other changes to strengthen our systems and processes to ensure continuity of care when people are released from prison including completing an audit to ensure people in prison are being released with discharge summaries, health information, and prescriptions.
“This audit is to be added to the National Audit Schedule to examine the practice across all health centres.”
Dougall said Corrections was also using monthly meetings between its chief medical officer, custody staff and health staff to “continuously strengthen the process of notifying health services of all releases, including unexpected releases”.
After Isaac died his family paid tribute to him online.
“Misunderstood, broken, hurt, and tired would’ve only been a handful of emotions going through your mind,” said his aunt of his state when he died.
“Sadly Isaac leaves behind a daughter, a broken-hearted mother, a grieving grandmother and very distraught siblings.”
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