He had been moved between wards, slept in the lounge under a blanket and put into a converted interview room because the centre was at 120% occupancy.
Redwood found Trade Me listings for flats on a mattress on the floor of the room being used by Carter as a bedroom.
In findings released on Friday, Coroner Alison Mills ruled Carter’s death was self-inflicted.
She said while the failures did not directly cause the 35-year-old’s death, she believed that cumulatively, they contributed to the Raglan man’s sense of hopelessness and despair.
Carter had struggled with mental health and addiction issues since the age of 25 when he injured his back working on a large outback station in Australia.
He then became addicted to the pain medication codeine.
Despite that, Carter was given opioids for pain relief when he was admitted to hospital in New Zealand in 2017 with pneumonia.
By then, he had been diagnosed with paranoid schizophrenia and had been treated with antipsychotic medication, including olanzapine and paliperidone.
With a supportive community mental health nurse, Carter was able to live in a caravan on his father’s farm but he had a history of not taking oral medication, causing him to relapse.
The relapses made Carter violent and aggressive toward his family, and he assaulted his mother’s partner and one of his brothers.
A month before his death, Carter asked his in-patient psychiatrist Dr Jean Erasmus to change his medication from the paliperidone injection, because he was concerned side-effects would affect his ability to father a child with an American-based girlfriend.
Nurses suspected that girlfriend was a delusion.
Despite Carter’s recent history of not taking oral medication, which was noted by another doctor, Erasmus agreed and prescribed a daily dose of the tablet ziprasidone.
Coroner Mills said there was no evidence Erasmus planned to continue the paliperidone or that he took any steps to put monitoring in place, despite Carter’s history of non-compliance with oral medication.
At an inquest in November, Erasmus said he agreed to the trial to build a rapport and trust with Carter.
But Coroner Mills was critical of Erasmus for beginning the trial while Carter was on leave from the hospital at Pathways community housing, where staff were not clinically trained and did not monitor medication compliance.
She also said there was no evidence that effective steps were taken to ensure staff on the ward were aware of Carter’s risk of not taking his medication, with the nurse who approved Carter’s leave on the day he died testifying she was unaware of his history of non-compliance.
The single dose of 60mg at night without food was also criticised because it was lower than recommended and heightened the chance of relapse, as did the discontinuation of paliperidone.
Carter likely never took his new medication
After Carter died, a post-mortem examination detected therapeutic doses of olanzapine and paliperidone, though the latter was likely wearing off, but no ziprasidone – leading the coroner to conclude Carter never took it.
The coroner was also critical that there was no thorough psychiatric assessment of Carter while he was in hospital and said red flags that he was relapsing were not investigated.
She said the leave procedures at the time of his death were poor – a nurse simply asked Carter how he was feeling, to which he replied “safe”, before she approved the walk on which he would take his own life.
Carter, who was due to be discharged the following day, left the facility at 8.15am after agreeing to 30 minutes of unescorted leave.
The absent without leave process was not activated when he did not return.
This was despite the fact that Carter was considered a danger to his family and they were supposed to be notified if he was AWOL.
Instead, the nurse gave him an extra 90 minutes.
When she was phoned at 9.20am by the centre manager, asking if anyone was missing from the ward, she said no.
Coroner Mills was also critical of the centre’s poor engagement with Carter’s family.
Redwood described years of trying to advocate for and be involved in her son’s care, to no avail.
“Jenny’s calls were not returned, she had to repeat the same information over and over again, and she felt their voices were not heard and had no practical way to be heard.”
Redwood only got a face-to-face meeting with a psychiatrist about her son after he died.
Coroner Mills also expressed concern at the lack of accommodation both in the hospital and the community.
She said she was concerned that a new facility being built to replace the Henry Bennett Centre would have fewer beds than it did currently.
She said Carter, whose reason for not wanting to return to Pathways was never explored, was too sick to live on his own, but well enough to recognise the bleakness of his situation with discharge imminent and nowhere to go.
He had already previously been discharged to a backpackers and his family were not made aware of the latest discharge plans.
Mother believes change unlikely despite recommendations
Redwood said during an earlier discharge, a nurse told her Carter was luckier than most because he at least had a car to sleep in.
“If Joseph had had the support, and it wasn’t a lot of support, then he was not homeless and he could have lived and stayed in the community,” Redwood said.
“I tried to say repeatedly ‘this is all he needs and he does have family to support him’ but it just got worse and worse and worse. Nobody listened and really, genuinely, nobody cared.”
When well, Carter was a bright, kind, caring man and a talented musician who at one point had his own recording studio, Redwood said.
She was not hopeful of any significant change in the system.
Coroner Mills recommended Te Whatu Ora Waikato make it easier for nurses to identify patients known for not taking medication, consider a primary nurse for each HRBC patient, consider incorporating advanced directives so that patients could make their preferences known while they were well, amend the leave form so an agreed return time could be recorded, and review the leave policy to consider amendments to ensure proper risk assessments were not undermined during times of lower staffing, such as weekends.
She also recommended a review of discharge planning, ongoing education for staff on family engagement with regular audits of the current policy, and implementing systemic reviews for all serious event reporting.
The coroner also recommended Pathways conduct serious event reviews in cases like Carter’s.
Although she did not make any recommendations related to Erasmus’ clinical practice, she provided a copy of her findings to the Medical Council.
Advocate appalled at repeat issues
Jane Stevens, the mother of Nicky Stevens – who took his own life after leaving the HRBC on unescorted leave against the express direction of his parents – said she was shocked by the changes to leave that had happened in the time between her son’s death and Carter’s.
In December 2018, Coroner Wallace Bain found Nicky’s death in March 2015 could have been avoided if mental health staff had followed Stevens and husband Dave Macpherson’s advice that he not be allowed on unescorted leave.
Stevens said Coroner Mills had highlighted the same issues that were major factors in contributing to 21-year-old Nicky’s death.
Those included unsafe leave procedures, failure to undertake an appropriate risk assessment, high staff turnover, lack of training, poor communication between management and staff, failure of systemic process, and extreme and ongoing overcrowding, she said.
“I was utterly shocked by the lack of safety around unescorted leave. It’s actually got worse since Nicky died and it was a major factor in his death.”
Stevens said this was particularly “gutting” because she and Macpherson, a former Waikato District Health Board member, had worked hard to advocate for change to make HRBC a safer place.
“Despite repeated claims of change having been implemented by management, nothing substantially changes and people keep dying preventable deaths, leaving whānau devastated and wanting answers.”
Stevens said Coroner Bain made a series of recommendations including establishing an independent authority to review deaths, serious incidents and complaints, which had not happened.
She called on Minister for Mental Health Minister Matt Doocey to take action.
In a statement, Doocey said his thoughts were with Carter’s family and friends.
“I have asked Health NZ to update me on the implementation of the Coroner’s recommendations.
“I’m open to meeting with Jane Stevens and the Carter family to understand how we can make meaningful change.”
Health New Zealand responds
A Health New Zealand Te Whatu Ora spokesperson declined an interview with RNZ.
In a statement, they said a series of initiatives had been introduced since 2019, including an improved care planning document to strengthen communication between clinicians.
There had also been updates to the AWOL procedure, ongoing audits including around discharge and leave planning, an increased focus on family engagement, and a new national policy introduced for incident reviews.
There were new staff roles including a whānau community advisor, a family facilitator, and Māori clinical nurse specialist and Kaitakawaenga roles.
The service was also involved in a research project on advance directives.
However, Te Whatu Ora said the coroner’s recommendation to adopt a primary nursing model in the acute ward would not be implemented.
“While this model is used in our forensic facility, it is not applicable in the acute wards due to the ongoing high demand, plus shorter stays generally seen in this ward.”
Instead one nurse was identified for each patient each day to improve communication and handovers, and patients would have an identified social worker and responsible clinician on admission.
The spokesperson said giving patients the opportunity to take leave remained a critical part of the recovery process and a policy remained in place for how this was to be approved and managed.
Te Whatu Ora said it was aware specialist mental health services were experiencing high demand and occupancy across the country and work was under way on a new acute adult mental health facility in Hamilton.
The spokesperson said the facility would add four beds, contrary to the coroner’s concerns, while a further 10-bed unit had been approved to support people with high and complex needs.
“This will include a new community-based intensive rehabilitation service.”
Where to get help
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
- Lifeline: 0800 543 354 or text HELP to 4357
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
- Depression Helpline: 0800 111 757 (24/7) or text 4202
- Samaritans: 0800 726 666 (24/7)
- Youthline: 0800 376 633 (24/7) or free text 234 or email talk@youthline.co.nz
- What’s Up: free counselling for 5 to 19-years-old, online chat 11am-10.30pm seven days a week or free phone 0800 WHATSUP / 0800 9428 787 11am-11pm Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi and English.
- Rural Support Trust Helpline: 0800 787 254
- Healthline: 0800 611 116
- Rainbow Youth: (09) 376 4155
- OUTLine: 0800 688 5463 (6pm-9pm)
If it is an emergency and you feel like you or someone else is at risk, call 111.
- RNZ
