KEY POINTS:
The inquest into Shane Fisher's death begins with a song.
"This will be a difficult day for you," says Dr Murray Jamieson to Shane's parents. "And I want to express my sympathy."
At their request, says the Auckland coroner, the court will hear "a recording by the late Shane Fisher, an accomplished guitarist".
There's an awkward moment. The music plays in fits and starts. The registrar gets up, sits down and then gets up again. Mercifully, the track settles and Shane's melodious acoustic guitar and voice eerily fill the courtroom.
The tribute is a poignant reminder of a life cut short. The stuttering start has resonance too - Shane's story has waited 29 months to be heard.
For years Shane lived in a world of spirits, visions and astral travel, a world where he saw himself as a leader of angels. But on May 18, 2006, with new medication, Shane reveals he does not feel controlled by spirits, does not see visions or hear the angels commanding him, and is not having thoughts put into his head.
The medication is clearly working, but there is a tragic side effect. The loss of his auditory hallucinations, his psychotic world, is also a loss of his identity. Shane is missing his angels and is talking about self-harm as a way of rejoining them.
Two days after the final review he was to have at Te Whetu Tawera, the Auckland District Health Board (ADHB) acute mental health unit which was caring for him, Shane was found dead at home.
The question at the centre of the inquest into his death is whether someone as unwell as Shane received the proper level of care. It's a question that goes to the heart of the recovery-based ideology that guides our mental health services.
It's a question that asks whether there are gaps in that service - whether it has the expertise and resources to deliver its goals.
Whether Shane was given the time and support he needed to get better, or whether a service under strain pushed him back into the community before he was ready. At the end of the two-day inquest, the coroner finds Shane's death, on May 20, 2006, was self-inflicted and intentional and that no other person was directly responsible. Shane was 26.
Suicide. It's what everyone knew when it happened, but only now, such is the legal taboo on uttering the word, can it publicly be uttered.
Normally, that would be the end of it - name, address, occupation, self-inflicted death - another statistic to add to the 500 or so who die this way each year. Our Coroners Act prohibits the publication of details of individual suicides. And no one can publish that the death was by suicide until the coroner says so.
But Shane's case is different, largely because the family wants the inquest evidence made public. It's an unusual circumstance disrupting the logic behind the Coroners Act: that the family and friends of anyone who commits suicide suffer enough grief without having it played out in the news media. Normally, suicide is nobody else's business.
The Fishers disagree. They want the information to come out to highlight the plight Shane, and others like him, face under what they view as a mental health service in chaos.
Thanks to their courage, and Dr Jamieson's lifting of the publication prohibition - in the hope some "good could come out of the death of a much-loved son" - the wall of silence of what happens in a suicide inquest is broken through.
The two days are an emotional buffeting: a mother's anguish and frustration; the shock and response of mental health care staff when a suicide occurs on their watch; a glimpse into the complexities of mental illness; the tragic effects of suicide on a family; plus the enormity of trying to understand why someone decides to take their own life.
"This is not a trial, it's an inquisition. No one is on trial here," says Dr Jamieson sitting under a Ministry of Justice crest at the judge's bench. Shane's mother, Sally Fisher, with the support of husband Michael, is representing herself. Harry Waalkens, QC represents one of the staff at Te Whetu Tawera.
The, ADHB is represented by Meredith Connell solicitor Claire Campbell, who is on the firm's medico-legal/public liability team. Already, it seems an unfair fight.
Police Sergeant Frederick Potts begins with the grim details - including the means of Shane's death. Such information is freely discussed here in open court, but is almost always strictly suppressed for publication.
The general prohibition is supported by both the Ministry of Health and Suicide Prevention Information New Zealand (Spinz), an agency of the Mental Health Foundation. The concern is that reporting the how of suicide, especially in a sensational manner, may lead to copycat self-inflicted deaths.
What we can say is Shane was diagnosed schizophrenic, had attempted suicide before and was found dead at home, by his younger brother. The onset of his illness is thought to have been triggered by a traumatic event - the death in 1998 of his brother Glen of meningococcal septicaemia.
Glen was 17, a year younger than Shane. The family tragedy was compounded by a 2002 coroner's finding of "poorly organised and inadequate" care at North Shore Hospital, which wrongly diagnosed Glen's condition as an influenza-like illness when he arrived at the Emergency Department.
Sally Fisher recalls her previous experience in coroner's court - coincidentally, also before Dr Jamieson - battling for Glen.
"Today I am once again confronted by lawyers - their fee being subsidised by taxpayer dollars. I find this distressing, disturbing and immorally wrong."
She says the lawyers' adversarial focus on achieving the best outcome for their client - "the sanitation of the truth" - doesn't help either.
"The determination of DHBs to refuse responsibility and avoid culpability needs to be addressed." As an example of insensitivity, she points to a letter from the ADHB apologising for the delay in writing to the family, as was agreed, following mediation. It was an apology that came 14 months late.
Fisher stays in combat mode for most of the inquest. Dr Jamieson often patiently reminds her that this is an inquiry into Shane's death, not a commission of inquiry into the state of mental health services in New Zealand. And that she needs to frame a question rather than make a statement and allow those giving evidence, time to answer.
Fisher: Is Lorazepam addictive? Yes or no?
Coroner: You don't need to say yes or no.
But she also takes time to talk about her son - the eldest of five children, intelligent, an avid sportsman, talented and passionate musician, keen surfer and conscientious student with a wide circle of friends. "He had a very full life and was a very happy and contented child, idolised and admired by his siblings ... we were very privileged parents."
At Rosmini College he obtained an A bursary in his seventh form year and also passed Trinity College exams for both speech and music.
In his school reference the headmaster writes: "Shane is an open, friendly, mature individual who comes from a very supportive family, responds positively to authority and relates well to peers and adults."
The inquest covers three broad concerns: what happened at the unit on the day of Shane's death; what happened in 2005 when Shane decided to live in Wellington; and what options Shane had for rehabilitation.
The names of ADHB staff directly involved in Shane's care are suppressed, on the grounds that media coverage could affect the therapeutic relationship between psychiatric staff and patients currently in the unit.
On the morning of May 20, 2006 Shane slept late and although he was checked on three occasions, didn't speak to his nursing staff.
After lunch the nurse assigned to Shane for the day shift noticed he wasn't in his room and was subsequently told by another nurse he had gone on leave and would be back by 7pm.
Shane's mother asks why she wasn't phoned, as was usually the case when Shane left the hospital to walk to his home. She's told it wasn't routine practice. "But I received a call most days on my mobile," she argues with the person she's questioning. She produces a handwritten note from Shane's medical file which says "please inform parents".
The board says the note referred to Shane's previous admission. It's also argued that day leave was beneficial and important for Shane's recovery and "for having a life worth living". Another member of staff says: "If a family member requests phone calls, I respect that."
ADHB counsel points out, too, that Shane took leave the day before his death without any problems.
Then there are questions about whether an adequate safety check - to make sure Shane didn't have suicidal thoughts - was carried out before he left the hospital. The ADHB maintains there was an assessment. Fisher asks if there was, why it isn't recorded in Shane's case notes.
On news of Shane's suicide, staff on duty that day were called back for a "defusing" that evening . "It involves relevant staff talking about the event, making sure everyone is okay and making plans for what happens after that," explains one of the staff. What does happen after that is staff are asked to "expand on the notes written that day" - changes which show up on the "Health Care in Community" computer record as several different versions of events.
Dr Jamieson asks those giving evidence a few questions.
Coroner: How might this sort of tragedy have been prevented?
Psychiatric nurse: If the intent is there, we can't always prevent it.
Shoddy note-taking is a recurring theme in Fisher's questioning. As a registered nurse, and co-owner of a private health care service, she is unable to contain her dismay at what she finds - wrong names, wrong dates, corrections made and not initialled. Some of what's revealed seems to concern the coroner too.
"Again, I'm not happy about that," comments Dr Jamieson when shown another error. Director of the ADHB's mental health services, Dr Nicholas Argyle, says it's important to strike a balance between adequate detail in patients notes and taking down too much detail costing clinicians time with patients.
AFTER several years of deteriorating behaviour and refusing to see doctors or accept counselling, Shane had his first psychotic attack in 2002 and was committed under the Mental Health Act. His mother recounts a string of examples of poor supervision and care. There are further psychotic attacks and re-admissions in 2003 and 2004.
But it's Shane's decision to move to Wellington in 2005 while under a compulsory treatment order that Shane's mother says illustrates most vividly the failures of the system. The move, supported by Shane's Community Mental Health Team, involved weekly phone calls to check on progress. Fisher asks how it's possible to check on someone's mental health by telephone, especially when they're often non-compliant with their medication.
"It was an encouragement of independence. I had faith in Shane," says the psychiatric nurse. It was a faith short-lived. Within eight weeks Shane was requiring urgent admission to Capital Coast Health's Mental Health Unit. But it didn't go smoothly - the unit had no record of who Shane was.
Fisher: Why were no notes sent to Wellington?
Psychiatric Nurse: The process was delayed and that was regrettable.
Shane returned to Auckland where he was given fortnightly injections of Risperidone by the Community Mental Health team. He was readmitted to Te Whetu Tawera on Boxing Day in 2005, returning home in mid-February. Shortly after, Shane tells people he would "do away with himself" if the intolerable headaches he was experiencing didn't cease.
He does attempt suicide on March 20 and is re-admitted. He remains in the unit with the right to unescorted leave until his death in May.
It's during this period that psychiatric staff determine Shane is non-responsive to Risperidone. They are mindful that headaches and migraines are a documented side effect of the drug. But with a change in medication and a reduction in the headaches, another problem emerges. With the diminishing of his psychotic world, Shane is also feeling a loss of identity.
"While still psychotic but beginning to respond to treatment he told me on 10 April 2006 that he noticed the withdrawing of the angels, he was missing them and he considered self-harm to rejoin them," says one of the psychiatric staff.
Tragically, at the same time, Shane, who had been unable to accept he had a mental illness, was starting to make significant positive changes, including stopping using alcohol and marijuana.
"He had made good progress and wanted to stay to get treatment. He was beginning to get insight and engage with his problem."
Fisher focuses on an event on May 17, three days before his death, where Shane became very agitated, threatening to bang his head against a wall until he received Lorazepam which he knew would help with his anxiety. She asks about a review of the incident and why the suggestion that leave should be suspended for three or four days wasn't followed.
"We made a careful risk assessment on the decision of leave. The clear thing for me was he was not suicidal. Shane was engaging and returning from leave to the unit when he had anxiety," explains one of the staff.
Throughout this period there is another conversation going on - the options for Shane's discharge. His mother had rejected the home option. "If I had agreed for Shane to come home he would have been discharged. I had not agreed for him to come home because he would be alone."
All agreed the best option would be the Buchanan Rehabilitation Centre - and letters of referral were sent. But there were no vacancies and Shane faced a year-long wait to get in.
Several ADHB staff acknowledge the lack of sufficient facilities of this type is a serious problem, but say also that despite the recommendation for Shane to go there, he wasn't yet ready to be discharged. Shane's mother is dismayed by the revelation.
It's not something she's been told before and she struggles to reconcile the new information with the fact Shane was allowed unescorted day leave and suggestions he should be discharged to live at home.
What also emerges is an ongoing problem at Te Whetu Tawera described as "bed pressure". One of the staff explains: "The unit is often full. We often have to look who can be discharged to get an admission."
Shane's mother says her son was in limbo - needing rehabilitation, but with nowhere to go. That the system and the problems she has outlined let him down and contributed to his suicide.
Dr Argyle agrees more options for discharge would be desirable, but points out the wait for the Buchanan centre is now several months, not a year as it was in 2006. He also maintains the lack of resources was not an issue in Shane's case - that he received adequate care from the community and in-patient services.
The inquest draws to a close and the coroner reserves his findings. On several occasions he has asked: Do the tools available to modern psychiatry have the ability to predict suicide? And: Was there anything that could have been done to prevent Shane's death? Psychiatric staff answer "no" to both questions.
Shane's mother closes with a plea to the ADHB to "go to the right places and ask the right questions" if they need more funding. And to be more attuned to parents' concerns. "Mothers do know more and do understand."
SUICIDE FACTS
* In the year to the end of June, 511 suicides were reported to coroners - 1.4 self-inflicted deaths a day.
* Suicides accounted for more than one-in-three coroners' cases.
* There were 419 road deaths in the same period.
* Suicide numbers have fallen since a peak of 577 in 1998 but have been rising since 2004 when there were 488 suicides.
* The 2005 suicide rate of 27.6 deaths per 100,000 for males aged 15-24 years is second highest among OECD countries.
