WARNING: This story deals with the issue of suicide and may be distressing.
Ziporah Huirama never had a chance.
In 1992, at age 3, she was sexually abused by a member of the church her mother belonged to.
It was to be a trauma she would never fully recover from, compounded by more than a decade of state care where she was bounced between institutions, kept from her whānau, over-medicated, secluded, neglected, and allegedly raped.
Her nightmare ended when she died in a suspected suicide in 2016.
She was 27.
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But Ziporah, who also went by the name Esther Osborne, might have stood a chance if her Māori heritage had been nurtured and respected by the organisations charged with her care.
If her whānau were allowed to be more involved. If their concerns and complaints had been listened to.
If Crown policies, practices, acts and omissions through its agents had not been prejudiced against Ziporah because of her culture and skin colour.
That is the claim to the Waitangi Tribunal being made by Ziporah's mother Tasilofa Huirama.
The claim, lodged in late May 2019, will be presented to the health services and outcomes kaupapa hearings before the tribunal this year.
They are just one of a series of kaupapa hearings on issues around Māori rights and the belief that colonisation and the broken promises of the Treaty of Waitangi have led to Māori loss of life, including by suicide.
Turbulent childhood
Ziporah Grace Huirama was born on May 31, 1989, the fourth of seven daughters.
Her mother, Tasi Huirama, grew up with an abusive father who she fled from soon after her mother died.
It threw the 12-year-old Huirama into a life that revolved around the Black Power gang in Wellington.
She became part of the Aroha Trust, the first women's working co-operative in the late 1970s and goes some way to explaining her total commitment to an evangelical religion years later.
Huirama, who wore all black and wasn't allowed to cut her hair as part of the instruction of the church, says she was in hospital having another child when Ziporah was being sexually abused.
The offender was eventually convicted of abusing other children. The trauma marred the young girl's life.
By age 10 Ziporah was committing burglaries and vandalising property with tagging. At 12 she was introduced to cannabis by friends and health records indicate she may have sniffed solvents.
In August 2002, at 13, she was hospitalised with cannabis poisoning.
Oranga Tamariki, then CYFS, became involved because of alleged domestic violence in her home. At one point Ziporah was living in abandoned school buildings with two siblings.
In April 2003 Ziporah and three younger siblings were placed in foster care but her behaviour became more aggressive, health records seen by the Herald state.
At the same time, Huirama claims she experienced discriminatory targeting by the Crown agent after an argument with a CYFS worker.
Four months later, when Ziporah was 14, she was hospitalised after ingesting Datura - a poisonous plant that causes hallucinations, psychosis, breathing problems and temporary blindness.
It was after that incident that Ziporah's mental health began to deteriorate.
Escalating mental health
Growing up, Ziporah was good at sport and maths, Tasi Huirama says. She wanted to be an accountant and with her mother in a band, Ziporah also liked to sing.
But petty offending and aggressive outbursts resulted in a referral for forensic assessment to the Child Adolescent and Family Service in her home town of Whanganui in November 2003.
"Esther [Ziporah] was observed by her social worker to be experiencing hallucinations and uncontrollable laughter," the notes state.
"She was seen to be talking to herself and following imaginary beings around the room with her eyes and speaking to them."
The next month Ziporah was added to an "at-risk" register and admitted to hospital a second time for datura intoxication.
She was admitted to Te Awhina Adult Mental Health in Whanganui but ran away after five days.
There was an attack on her sister with an iron bar, a crisis team, police involvement and another referral to Te Awhina and then to a regional adolescent inpatient unit.
In February 2004, CYFS was granted guardianship and through that process her whānau took her to a psychiatrist who did not diagnose any mental illness.
Only weeks later Ziporah self-harmed, cutting her arm, and she was diagnosed with a personality disorder but she was not admitted anywhere.
The following month Ziporah was to be transferred to Puketai Residence in Dunedin, a secure care home for up to eight children aged between 10 and 16.
"CYFS told the claimants that Ziporah would only be away for three weeks," the statement of claim before the Tribunal said.
"On the day she was to go to Dunedin, Ziporah was scared and took an overdose of Colchicine, which were prescribed to her father for gout."
Huirama discovered the overdose as Ziporah was being transferred to the airport and requested an intervention.
"CYFS refused to intervene," the statement said.
In Dunedin she was hospitalised for impaired kidney function, suffering seizures, breathing obstruction and high blood pressure.
"She was intubated in intensive care and subsequently suffered more seizures and then a stroke," the health notes say.
An MRI showed significant cerebral and vascular brain damage. She was left with speech problems and difficulty swallowing but a left-sided weakness improved, allowing her to return to walking unaided.
Huirama was flown to Dunedin and Ziporah's condition improved but she was not allowed to return home.
"Although her medical condition quickly improved her mental state exhibited signs of being distracted with poor concentration, emotional liability and incongruence and intermittent aggression," the medical notes state.
Ziporah was diagnosed with conduct disorder and behavioural and mental health disorders related to her polysubstance and use of solvents.
Polysubstance is when a person is psychologically addicted to being intoxicated.
She ran away from Puketai at least once.
In June 2004, Ziporah was sent to Odyssey House in Auckland, a drug and rehabilitation unit.
According to the statement of claim, Ziporah walked out on her third day at Odyssey House, came back a few days later and then left altogether.
"While absent from Odyssey House, still in the care of CYFS, Ziporah was raped by two men," the claim says.
"She was put by CYFS into a cell in Weymouth Residential Youth Prison for the weekend before she was flown back to Puketai.
"Although the whānau told staff at Puketai that Ziporah had been raped in Auckland, she received no treatment for the trauma she experienced."
She was 15.
Antipsychotic medication introduced
In January 2005, Ziporah was admitted to Te Waireka, a former residential drug and alcohol rehabilitation unit for youth in Napier.
It was around this time the teenager began experiencing anxiety.
A month later Ziporah was discharged from CYFS care and returned home to Whanganui.
By April she had a crush on a man more than twice her age, who was also dating someone else.
An altercation ensued between the other woman and Ziporah who stabbed the woman with a kitchen knife.
She was arrested and charged with attempted murder.
According to the statement of claim, police refused to let Huirama visit or speak to her daughter.
Ziporah was remanded to a secure unit at Youth Justice North, a prison for young people, while she awaited trial.
She first reported hearing voices, that were worse at night, at the prison.
In June 2005, Ziporah was forced to take antipsychotic medication Risperidone according to Huirama, who says it began a marked decline in her daughter's mental health.
Risperidone side effects include drowsiness, apathy, agitation, excitement, insomnia, convulsions, dizziness, headache, confusion and renal impairment.
A cognitive assessment scored Ziporah an IQ of 92, just below average.
It was almost a year and just before her 17th birthday when Ziporah appeared in court to face the attempted murder charge.
The charge was downgraded to wounding with intent to cause grievous bodily harm. Ziporah was convicted and sentenced to 3 1/2 years in jail.
She continued to be held at Youth Justice North until she was transferred to a drug therapy unit at Arohata Women's Prison in Wellington.
Health records state Ziporah was in solitary confinement for at least a month but Huirama says it was 11 weeks, "with no one to talk to".
On one occasion Ziporah was caught whistling after being told not to, her mother says.
She was "restrained" by three staff who "threw her into her cell".
Ziporah's mental health declined further and she stabbed herself in the stomach.
The serious wound required surgery but Huirama said it was still relief she saw on her daughter's face when the whānau visited her in hospital.
"We had her for two weeks and she was just normal."
After that, she was transferred to Rangipapa Forensic Medium Secure Unit, a mental health care facility for men and women.
Huirama was prevented from visiting her daughter for the next six months and said Ziporah complained of having to take so many pills they were "coming out her nose".
These included other antipsychotics Quetiapine and Clozapine, which Ziporah was allergic to, suffering myocarditis - inflammation of the heart muscle.
She was also taking Sodium Valporate which is usually prescribed for epilepsy and bipolar disorder, and Metformin to treat Type 2 diabetes.
"Ziporah was hallucinating and screaming under the medication and was not provided with any whānau support," the statement read.
"Ziporah told her whānau she was petrified of the psychiatrists; she was on 310 pills per week and was often in a comatose state."
Huirama described the amount of medication her daughter was taking as "crazy".
"Why did they have to do that to her? She was only 17."
Drugs, diagnoses, escapes ... then death
Throughout the next 12 months, Ziporah's life consisted of a cycle of violence, assaulting other patients, being assaulted by patients, and being restrained and secluded by staff.
In November 2007, Risperidone was exchanged for Olanzapine, a short-term use drug to control disturbed behaviour.
"Around this time, Ziporah started developing a lisp."
Huirama was finally able to visit her daughter, initially only every three months for 30 minutes and after that more frequently.
By January 2008, her IQ had dropped to 86, below the average of 100 but above the range with developmental delays.
Despite being in a secure unit Ziporah's urine regularly tested positive for cannabis.
In May 2008, Ziporah escaped Rangipapa and fled to her mother's home. She was returned by police two weeks later.
In November that year her prison sentence ended, she was detained under the Mental Health Act but discharged 10 months later.
Within a month Ziporah was admitted to Te Awhina Inpatient Acute Mental Health Service in Whanganui but ran away.
Police brought her back against the wishes of her whānau who said Ziporah was "doing well at home".
In December 2009, Ziporah was prescribed Aripiprazole, a drug used to treat schizophrenia and bipolar disorder.
When the 20-year-old attempted to take her own life six weeks later, it was decided she could not be transitioned back into the community and Ziporah was transferred back to Rangipapa.
"While at Rangipapa, Ziporah felt harassed and bullied by the staff who would follow her around during and after she talked with her whānau, and if they heard her crying, they would corner her, strip her in order to 'de-escalate' her emotions and place her in seclusion," the claim states.
After 18 months Ziporah was moved to Tāwhirimātea Rehabilitation Unit in Porirua, a long-term low secure unit with 29 beds.
There the de-escalation area was in the male patient section and Ziporah witnessed screaming men wandering the unit in various states of undress, the claim said.
"During her time at Tāwhirimātea, she was sexually harassed by a male staff member and in response to her complaints, locked in solitary as punishment.
"This resulted in Ziporah learning to suppress her emotions."
By 2011 Ziporah was medicated with Olanzapine, Quetiapine, Sodium Valproate, Carbamazepine, Metformin, and Lorazepam which left her virtually asleep all day.
Huirama claims her daughter was told by staff she could not leave the unit because "she might kill someone".
"Ziporah became too scared to leave."
According to the claim, she talked about taking her own life for weeks before she died.
Her whānau warned staff of this, according to a serious event review of what happened next.
On July 1, 2016, Ziporah became upset and was overheard by staff complaining that "no one cares for me here" and "I hate all of you".
She told her family she wanted to leave the unit, the same one where intellectually disabled man Ashley Peacock lived for eight years before a Herald investigation helped to free him.
Ziporah was taken for a walk outside and through tears told a nurse she wanted to kill herself and how she intended to do it.
"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," the review said.
Her threats were not told to staff managing the de-escalation unit by the nurse when the pair returned.
The Herald is restricted from reporting the method of any suicide and must refer to Ziporah's death as a suspected suicide until a Coroner makes a ruling.
Ziporah was left alone in the de-escalation unit, against Capital and Coast District Health Board policy for a patient threatening suicide, and a short time later she was found unconscious.
She died in hospital three days later.
Ziporah had been in the care of mental health services for almost 10 years.
"Through its actions and omissions the Crown failed to protect Ziporah's mental health," the claim states.
"As a result of the actions of the Crown agents, namely CYFS workers, Corrections, Ministry of Health psychiatrists, clinicians and health professionals, Ziporah was held in care for 11 years where she was subjected to inhumane treatment, harassment and bullying.
"This treatment led to the diminution of her mana, wairua and hauora.
"This diminution of Ziporah's wairua led to her early death after Ziporah lost all hope."
Huirama wants those responsible held accountable. She wants the Waitangi Tribunal to find that the Crown failed to protect her daughter.
"It was just the way they handled it. If she made a mistake, she paid for it. She didn't understand.
"The staff were more or less stripping her of everything. She had nothing. Her mother was gone."
Huirama claims at one institution a male staff member put his arm around Ziporah, who responded by punching him.
"Well then he punched her in the face. My poor daughter. She was just a little girl trying to get out of this.
"It was sad seeing her go through all these programmes and doing all this work just for them to fail her, days before she gets discharged."
Huirama said she didn't want another young person to go through what Ziporah did.
"It must have been terrifying for her."
A Capital and Coast District Health Board spokesman said the DHB again expressed sincerest sympathies to Ziporah's whānau, and acknowledged the loss of a family member in such circumstances was traumatic.
However, he said because of privacy issues the DHB could not comment publicly about Ziporah's treatment.
The Ministry of Health did not answer questions about mental health care, particularly for young Māori.
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 or 09 5222 999 within Auckland (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633 ,free text 234 or email talk@youthline.co.nz or online chat.
• 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
• SAMARITANS – 0800 726 666.