Warning: This story discusses suicide and mental health and might be confronting for some readers.
Finn Lowery had everything to live for.
A former top student and head boy at Rangitoto College, Lowery, 28, was also a celebrated law school graduate, captain of the New Zealand men's water polo team and a Rhodes scholar who studied at Oxford University.
Recently married to long-time girlfriend Rebecca and adored by his loving family, his life may have seemed outwardly perfect to many.
But in 2019 the 28-year-old was wrestling with a debilitating mental health condition, self-harming, and could see no reason to continue living.
At 8.20am on March 23 that year, Lowery was found unresponsive by his wife at his parents' Devonport home. He was rushed to North Shore Hospital and declared legally dead the following day.
A coroner's decision from Alison Mills has determined that Lowery's death was suicide. The 30-page finding outlines a series of deficiencies in Lowery's care, which his grieving family believe may have contributed to his death.
Those concerns were validated by a series of high level reports that the coroner says demonstrate "systemic" problems with the country's mental health system.
"The mental health services provided to Finn on his return to New Zealand were far from optimal and fell far short of what New Zealanders expect from a competent health service," the coroner said in her report.
"Unfortunately, the poor experiences of mental health services experienced by Finn and his family are not unique to them."
Waitematā DHB acknowledges "gaps" in Lowery's care and says it is deeply sorry.
"We recognise the impact the loss of Finn has had on his family and friends and we extend our deepest condolences," Specialist Mental Health and Addictions Services director Dr Murray Patton told the Herald.
Lowery's family are calling on authorities to fix the broken mental health system with proper resourcing to give other "precious souls" a fighting chance at recovery.
Descent into depression
The coroner's decision highlights that despite having a supportive and privileged background, Lowery fell victim to depression which ultimately claimed his life.
Lowery was the youngest of four children to parents Martin and Anna, including former Newshub journalist Sophie Lowery.
The gifted academic was awarded a prestigious Rhodes Scholarship to Oxford University in 2015, graduating top of his class in July 2018.
Lowery first developed mental health symptoms in 2012.
"As an intern at a law firm he reported feeling great anxiety and was afraid he would be 'found out to be a fraud rather than the excellent student they had expected'," coroner Mills said.
He suffered his first major depressive episode in 2015 while studying at Oxford when he self-harmed because of a fear of failure.
His father flew over to support him, accompanying him home later that year.
On his return, Lowery admitted spending hours thinking about suicide. He was referred to Waitematā DHB's community mental health service, and later admitted to Takapuna's He Puna Waiora adult inpatient facility.
Lowery "recovered completely" in 2016, working as a lawyer and travelling.
But he began seeing a private psychologist that year when symptoms reappeared.
In mid-2017, Lowery and his wife returned to the UK to successfully complete his Masters, but his condition deteriorated "rapidly and significantly" in 2018 after he reduced his medication.
Lowery was again self-harming, telling his wife "he did not want to end his life but was just crying out in pain," the coroner's report said.
His family again travelled to the UK to support him and Lowery was eventually admitted for treatment as a compulsory patient under the UK Mental Health Act.
He had feelings of hopelessness about the future and felt guilty about the burden he was placing on his wife, family and friends, the decision says.
He returned to New Zealand in December 2018 with an agreed plan that he be immediately admitted to He Puna Waiora upon his arrival.
No beds were initially available, however, and he was admitted two days later, which "did not go smoothly," coroner Mills said.
He and his family were left for more than two hours in a locked room without contact from staff or ability to call for assistance, causing "considerable stress and disquiet".
Lowery was considered high risk in the days that followed and had to be restrained.
He spoke about the triggers for his impulsive self-harm being frustration and anger with himself for not making more progress, "being a failure and deserving to be punished".
Over the next few months, Lowery struggled with his condition, while his wife and family tried to support him and get him proper care.
Despite his deterioration, he was put on a waiting list for community-funded psychological support and therapy sessions.
He reported "feeling a failure, that he was 'not good enough', and felt lost and
helpless," coroner Mills said.
In February 2019 Lowery had been offered a job in Tauranga but grew nervous at having to provide a psychiatric report to his prospective employer.
After his family physically stopped him taking his own life, his sister called the community assessment team but was told there was nothing they could do and to ring 111.
On February 19, 2019, the private psychologist said she could no longer treat Lowery privately because of his escalating risk, to the distress of his family.
But she agreed to "tentatively" resume treatment a month later after learning Lowery was still on the waiting list for psychological help and yet to receive therapy.
The decision notes she was frustrated with He Puna Waiora's poor communications and failure to provide her with a co-ordinated safety plan or risk assessment.
'A lot to live for'
In the week leading up to his death, Lowery attended a wedding and went fishing with his dad. But he was subdued, feeling he had "messed up his life" and lost an opportunity by returning from England.
The coroner noted that Lowery had a lot to live for. He'd led a successful and privileged life, had a loving family and enjoyed success both academically and in sports.
The young man had many "protective factors" that should have reduced his suicide risk.
"Finn's family describe him as desperately wanting to get well and get his life back
on track. However, Finn's medical notes also record that, at times, he expressed a desire not to live, felt incapable of living in the world and had feelings of failure," coroner Mills said.
"While it is difficult to understand or explain, ultimately, it appears to me that Finn
found living with his illness too difficult. He perhaps gave up hope of getting better and could not see a way forward."
The decision notes significant concerns from Lowery's family about the care he received and whether deficiencies contributed to his death.
The family met with the DHB several times to discuss their concerns and were committed to advocating for improvements in mental health services.
"Their motivation was to ensure that no other family suffered the loss they experienced," Mills said.
The coroner noted that Lowery's death came amid a "cluster" of Waitematā DHB mental health patient deaths in 2019. These included two suicides in the He Puna Waiora unit within four days, which led to a damning 2020 review.
An Adverse Event Investigation Report into Lowery's death highlighted areas for improvement which "validated many of the concerns raised by Finn's family", the coroner said.
Likewise, the 2020 He Puna Waiora Review Report "confirmed that many of the concerns raised by the Lowery family were valid, indicating that the problems at He Puna Waiora were not unique to Finn and his family's experience and were systemic".
The coroner recommended Waitematā DHB progress the He Puna Waiora Review Report's numerous recommendations and for the Ministry of Health to urgently address the shortage of trained mental health workers.
This shortage was creating significant access problems for sick people needing urgent treatment, with often devastating consequences.
Patton said Waitematā DHB fully accepted the coroner's findings, which identified gaps in the co-ordination and management of Lowery's mental health care upon his return from the UK.
Significant improvements had been made at the He Puna Waiora unit since Lowery's death, along with progress reducing wait times for mental health services.
"We are committed to continuous improvement within our mental health service to meet the needs of our service-users and their loved ones. We have a group of people with lived experience to work with us on this programme as part of this commitment," Patton said.
"The input of the Lowery family in assisting us with this process is valued and appreciated. We hope to continue this work together to minimise the likelihood of other families sharing their experience in future."
Lowery's family told the Herald he'd lived a full and happy life for most of his 28 years. His biggest achievement was being a much-loved husband, family member, friend and advocate for people in need.
The family agreed with the coroner's findings and implored Waitematā DHB and the ministry to act on the recommendations.
Mental health care had been grossly under-resourced for decades, they said.
"Proper resourcing and a commitment from central government to spend much more money on acute mental health care will enable unwell people to get better. New bricks and mortar won't make the difference, rather investment in well-qualified, empathetic acute care staff inside our hospitals and in community services will.
"Most people who experience mental distress recover and get well with the right support and care. These precious souls deserve what they would get in other acute care environments such as obstetrics, orthopaedics or emergency departments - a standard of excellence."
The family supported the Finn Lowery Foundation, which funds and facilitates mental health care in the sporting community Lowery loved.
WHERE TO GET HELP
If it is an emergency and you or someone else is at risk, call 111.
For counselling and support
Lifeline: Call 0800 543 354 or text 4357 (HELP)
Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO)
Need to talk? Call or text 1737
Depression helpline: Call 0800 111 757 or text 4202
For children and young people
Youthline: Call 0800 376 633 or text 234
What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
The Lowdown: Text 5626 or webchat
For help with specific issues
Alcohol and Drug Helpline: Call 0800 787 797
Anxiety Helpline: Call 0800 269 4389 (0800 ANXIETY)
OutLine: Call 0800 688 5463 (0800 OUTLINE) (6pm-9pm)
Safe to talk (sexual harm): Call 0800 044 334 or text 4334
All services are free and available 24/7 unless otherwise specified.
For more information and support, talk to your local doctor, hauora, community mental health team, or counselling service. The Mental Health Foundation has more helplines and service contacts on its website.