A young man granted unescorted leave from an acute mental health unit is believed to have died after entering the water at Takapuna Beach in search of Taylor Swift.
A leaked report into the incident has faulted the care provided by staff at Waitematā District Health Board, leading to policy changes to avoid similar tragedies.
But the man's grieving mother says she holds no ill will towards clinicians who let her beloved son leave the unit before he made his way to the beach.
Stephen Kapeli, who suffered from bipolar disorder, was a sectioned patient at Waitematā DHB's acute mental health unit He Puna Waiora in Takapuna.
His mother Sue Carter told the Weekend Herald part of her son's condition meant he'd developed an idolisation with US pop star Taylor Swift.
The family believe he was trying to reach her when he died.
The 26-year-old left the facility on approved unescorted leave on April 5, 2017. He was reported missing and his body was found by a woman walking her dog on Takapuna Beach almost a week later.
A "significant incident review" report into his death by the DHB has faulted staff for not alerting Kapeli's parents when he came off his medication.
It also found that clinicians should have considered his previous history, which included a manic episode five years earlier, before granting him unescorted leave.
But Carter told the Weekend Herald she held no anger or animosity towards medical staff, who did their best to help vulnerable people like her son under difficult circumstances.
"We as a family were absolutely, 'What do we do with our boy?'. These people were a lifeline. They were the ones who were going to help him get better again.
"I believe they made mistakes. I believe that if they had just looked at what was happening that day they might have made a different decision.
"But I don't have any anger towards them at all."
An independent review is currently under way at He Puna Wairoa after the suspected suicides of two other patients within days of each other in May this year.
But Kapeli's family are adamant their son did not deliberately take his own life and say police who investigated his disappearance held the same view.
He was committed to the unit in 2017, following an earlier compulsory admission in 2012.
Carter said her son's illness was exacerbated by synthetic cannabis, which he had used legally in previous years.
She recalled him as "the most exquisite, wonderful son - imaginative, creative and incredibly empathetic".
He also had an affinity with the water which would ultimately claim his life.
"He absolutely loved the water, that was his safe space."
On the day he went missing, Kapeli had learned he would remain sectioned in the unit and became distressed, Carter told the Weekend Herald.
But he was given permission for an hour's unescorted leave by a unit clinician, who assessed Kapeli as low-risk.
His family believe he made his way to the beach and entered the water trying to reach Swift.
Carter said her son was never suicidal and had been planning for his future.
"He was not wanting to end it. He was going to something and that something we believe was Taylor Swift."
Kapeli's death is currently under investigation by the Coroner's Office, which is yet to release its formal findings.
Police declined to comment while the matter was before the Coroner.
The DHB report, obtained by the Weekend Herald, says the decision by staff not to tell Kapeli's family he had refused medication "deviated from optimal care".
"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."
Specialist Mental Health Services acting director Dr Greg Finucane told the Weekend Herald the DHB extended its condolences to Kapeli's family and friends.
"We feel their loss and are committed to learning from any findings that can help to further reduce the likelihood of such a tragic event occurring again."
Following Kapeli's death, the DHB had improved policies around whānau engagement, meaning families were now informed of significant changes like a patient refusing treatment or medication.
It had also taken steps to ensure manageable staff caseloads to allow better monitoring of patients, and rolled out additional staff training to help assess "early intervention when a person's mental state is deteriorating or longitudinal history suggests likely relapse".
Despite the report's finding, Carter still refuses to apportion blame for her son's death.
"It's hard enough dealing with the loss of a child and grief let alone laying out negative feelings on top that you have to process.
"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."
Carter described many of the patients in the unit's care as "lost souls".
"These are kids who are just tortured. We just had our one beautiful boy. They have scores.
"I think they make a million judgment calls a day and on this one they made the wrong judgment call.
"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.