Esther Osborne was 27 when she died in hospital three days after an incident in a mental health facility.
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.
Māori make up 50 per cent of in-patients in forensic care under the Capital’s greater mental health system.
The statistic was quoted today as the coronial inquest into the death of Esther Osborne, a woman who spent over a third of her life “institutionalised” by the mental health system concluded.
“We need to be doing things differently,” a witness, who specialises in this area of care but has name suppression, said today. “That’s my ideal, that we would be caring for our own people and be given the resources to do that.”
Care for Māori patients starts in the community, for Māori, by Māori, she said today in the Wellington District Court before Coroner Janet Anderson.
On July 1, 2016, Osborne, diagnosed with schizophrenia, was found unresponsive in a de-escalation unit in 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.
Osborne had been “institutionlaised” for a decade, six of those years 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 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.
Coroner Janet Anderson at the Wellington District Court. Photo / Ethan Griffiths
The inquest has examined Osborne’s death for the purpose of determining how she died, if it was suicide, whether there were failings involved and, if so, what can be done to prevent further loss.
Two further witnesses involved in the mental health sector were called to give evidence today, both are subject to interim suppression orders.
The first gave evidence about the representation of Māori in the mental health care system, citing the figure of māori representation in in-patient forensic care to be 50 per cent under MHAIDS.
When probed by Coroner Anderson to speak about a “wish list”, her mind was turned to how better to support Māori patients.
She said changes that had occurred since Osborne’s death, including a focus on patients and their cultural needs, was a start, but more could be done.
“MHAIDS recognises there needs to be change and a better outcome for Māori,” she said.
The second witness spoke about the complaints process, how patients were supported in the unit and the changes that had been implemented since Osborne’s death.
When asked by the Coroner what needed to be implemented to ensure a tragedy didn’t occur in the future, he said it was a collection of things.
This included a coherent model of care, well-trained staff, more access to culturally responsive services, supporting whānau to spend time with patients and to provide hope and a pathway to the future.
There is an imbalance between the number of beds available for in-patient care and the number of community support groups, he said, which means guiding patients into a life outside of care can be difficult.
Osborne’s whānau spoke about the loss of hope she experienced while spending a decade in care. The witness said staff never give up hope for patients.
“You never give up, you keep trying different things and you put everything on the table, really, of options that could be helpful,” he said.
“I think that some of the processes we have in place now, in terms of the way services are organised ... I think they decrease the likelihood of these events happening again,” he said.
Although incremental steps and improvements have been taken, he said what has been implemented, especially in terms of cultural support, will strengthen over time.
“I think having more Māori clinicians and cultural specialists will make it easy to offer indvidualised approaches.
“I think those things are key. We don’t want it to feel hard for people to get the support they want and their cultural needs to be responded to.”
He also addressed allegations of abuse made by whānau, stating complaints had been investigated and he had an expectation all complaints were taken seriously.
Osborne, also known to family as “Ziporah”, was a cherished member of her whānau.
The inquest heard from many whānau members over the course of the two days – her mother Tasi Huirama, father Sam Huirama and sisters Abigail, Shalom and Rebecca Huirama.
Today they concluded proceedings with words about their cherished Ziporah. Waiata filled the court-room as family gathered to sing. They later said outside court It was one of her favourites.
Osborne’s mother Tasi made comments on the time it had taken to have her daughter’s case come before the coroner but thanked those who had supported her and the family.
Her sister Rebecca Huirama said she hoped the inquest into her sister’s death meant fair outcomes and protections for others, but also closure for the family as they forged new pathways together.
Coroner Anderson said she expected her findings to be released next year but acknowledged the time it had taken for Osborne’s case to come to the inquest stage.
“I am very conscious this inquest is taking place seven years after Esther passing away and it has taken far, far too long,” she said.
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.
