Esther Osborne was 27 when she died in hospital three days after an incident in a mental health facility.
Warning: This story discusses mental health and suspected suicide and may be distressing.
Esther Osborne’s ashes sit in a brown wooden box embellished with glow-in-the-dark stickers and a silver plaque.
It is placed on the desk in a courtroom, surrounded by whānau, some of whom are wearing T-shirts with her image on the front.
They were gathered hoping to find answers, and justice, as an inquest into her 2016 death, which occurred after she spent several years in a mental health facility, began today.
“It might have been seven years ago but the pain of losing Esther is still with us today,” her sister Shalom Huirama said in Wellington District Court.
“She didn’t deserve to die ... she shouldn’t have died that way.”
On July 1, 2016, Osborne, diagnosed with schizophrenia, was found unresponsive in a de-escalation unit at Tāwhirimātea, a specialist mental health in-patient facility in Porirua, Wellington.
The facility was under the umbrella of Mental Health, Addiction and Intellectual Disability Services (MHAIDS) operated by the then Capital and Coast District Health Board.
She had been “institutionalised” for a decade, with six of those years being in the Tāwhirimātea unit while subject to a compulsory treatment order, made under the Mental Health (Compulsory Assessment and Treatment) Act 1992.
Shortly before she was found unresponsive, she had told a nurse she wanted to die and described the way she would kill herself.
She was then given the instruments she said she would use to harm herself. Three days later the 27-year-old died in the Wellington Intensive Care Unit. Her death has been treated as a suspected suicide.
The inquest, set down for two days before Coroner Janet Anderson, will examine Osborne’s death for the purpose of determining how she died, if it was suicide, whether there were any failings involved and, if so, what can be done to prevent further loss.
“It is important Esther remains at the forefront,” Coroner Anderson said.
The inquest heard that Osborne had spoken with her dad Sam Huirama just days before she died.
She told him she loved him and missed him and spoke about plans for the future. She was studying and wanted to support her family.
“I’ve got to go now Dad, love you, bye.” It was the last time he would hear her voice.
Whānau were given the opportunity to speak at the hearing, during which they made moving statements about “Essie”, also known to her family as “Ziporah”.
Her mother Tasi Huirama, father and sisters spoke about a beloved and cherished woman who they described as intelligent, beautiful and as having had a lust for life.
“We’re here today as a family to see justice for Esther,” Sam said.
Osborne was described by her sisters as a person who was loving, impressive and always put her whānau first. Everything she did was for her family, they said.
“I wanted to be just like Esther, she was it,” Shalom Huirama said.
“She was beautiful, funny, smart all of those things but she made me feel important when I was younger.”
But when Osborne was made an in-patient of the facility under the treatment order, her family said they had no choice in the matter.
“Why are our people taken into your institutions, is it for them to die there?” Shalom Huirama said. “It’s not changing, obviously there’s something wrong with the system.”
The family alleged Osborne was abused while in care, and claimed at one point she was taking more than 300 pills a week to manage her mental health.
They also alleged the whānau were sometimes denied visits, that complaints weren’t properly addressed and that Osborne was “psychologically pressured” to stay in the unit.
Osborne’s mother Tasi said her daughter loved life and had big dreams but was stripped of her freedom.
“They pushed her into a corner and there was no way out,” she said. “We trusted them, we really thought they were going to care for her.”
Tasi said Osborne’s mana, wairua and hauora were diminished while under the care of MHAIDS. She spoke about the potential for treatment that better incorporated tikanga Māori.
Doctors directly and indirectly involved in Osborne’s care were called to give evidence. Both are subject to interim name suppression orders.
One doctor said staff at the unit had a strong connection with Osborne and had taken her care seriously, but he did not deny there were various challenges involved in caring for inpatients.
He said the loss of hope Osborne had experienced, described by her whānau, was concerning.
“Sometimes things don’t go as well as they should, but I think staff were doing the best they could.”
MHAIDS denied Osborne was abused while in care, but the doctor said if she was, he hoped it would have been reported.
“What I’ve heard this morning is distressing, what I’ve heard this morning is not how I want the system to be.”
It was accepted by one doctor the Mental Health (Compulsory Assessment and Treatment) Act 1992 was out of date.
Osborne’s older sister Rebecca Huirama, speaking via audio-visual link, said the family tried to remain as close as they possibly could to their sister.
“Humanity and compassion, all of those things that are lacking in the sterile world of mental health,” she said.
“In this space of mental health, how do we stop what’s happened to Esther, from happening again?
“We want to show up for Esther, we want to be here and be present for her today and every day.”
The inquest continues tomorrow.
Hazel Osborne is an Open Justice reporter for NZME and is based in Te Whanganui-a-Tara, Wellington. She joined the Open Justice team at the beginning of 2022, previously working in Whakatāne as a court and crime reporter in the Eastern Bay of Plenty.
The Rotorua law student who authored it says the support was 'overwhelming but inspiring'.