North Shore mental health unit patient took his life days after fellow patient’s suspected suicide

Tamaki Heke, 24, died by suicide in May 2019 at a secure North Shore mental health unit, just days after another patient took their own life.

Warning: Distressing content

When Rita Willcox phoned a North Shore mental health unit to raise concerns about the suicide risk of her troubled foster son Tamaki Heke, a nurse reassured her he was in “good care”.

Hours later Wilcox learned Heke was dead.

The 24-year-old, remembered as personable, talented, and creative, was found unresponsive in his room at Waitematā’s He Puna Waiora mental health unit on May 16, 2019.

A coroner’s finding has today ruled the death was self-inflicted.

It came just four days after a friend and fellow inpatient died in a suspected suicide at the same unit.

The double tragedy sparked a series of high-level investigations, including a damning independent review in 2020 which cited poor leadership, staff burnout, and suggested the building’s design assisted patients to take their own lives.

In today’s finding, Coroner Alexander Ho outlines Heke’s troubled background which included being diagnosed with ADHD and foetal alcohol spectrum disorder (FASD), and alcohol and drug abuse.

The decision also canvasses his extensive history of self-harm and suicide attempts.

Heke was first hospitalised in 2013. He reported hallucinations and was discharged after setting a rubbish bin fire and later charged with arson.

He was admitted to Takapuna’s He Puna Waiora for the first time in June 2016, and was in and out of the unit for the next three years.

In 2019, Heke attacked another patient and tried to choke them in a headlock after hearing “auditory hallucinations from demons”.

Tamaki Heke's worried family warned staff at the unit he was suicidal just hours before he was found dead in his room.

Days before his own death, Heke returned from an overnight stay with his foster parents, Peter and Rita Willcox, to learn a friend and fellow inpatient had taken his life in his room.

“Tamaki was distressed and reported intense urges of self-harm,” the coroner’s finding states.

Heke posted a message on Facebook saying: “Rest in peace my bro sorry I couldn’t be there to save your life the second time.”

He was briefly placed in a high-care area with closer monitoring due to his risk of self-harming.

The next day, on May 16, he told staff “I just want to die”.

Peter Willcox's foster son took his own life while under the care of clinicians at a North Shore mental health unit. Photo / Dean Purcell

Heke went on leave that day with family before returning to the unit about 6pm.

Soon after he rang his foster mother and sister, to discuss the song he wanted at his funeral.

Rita Willcox immediately rang the unit with concerns about his potential suicide risk.

A nurse’s entry recorded that Rita was “given reassurances that staff are aware of this and that he is in good care”.

The Coroner’s finding says Tamaki was unable to guarantee his safety, but told staff “I won’t do anything tonight”.

High care was not deemed clinically necessary. He was put on hourly observation checks but found unresponsive at 9.40pm.

Coroner Ho ruled that Heke’s death was a suicide, noting the recent upheaval in Heke’s life.

“There was evidence that he was contemplating ending his life that evening through the phone calls he made to his mother and sister in relation to his funeral song.”

It was likely he had “continued to ruminate” about this friend’s suicide after retiring to bed, then made “an impulsive decision to end his life”.

Coroner Ho ecohod earlier review findings that Heke’s FASD should have been his central diagnosis and focus of his treatment.

While staff were caring and capable, He Puna Waiora was “unable to meet Tamaki’s needs”.

“Tamaki was in He Puna Waiora because he had nowhere else to go.”

Heke’s FASD meant he was easily led and influenced by others, Coroner Ho said.

Placing him among people with serious mental health issues was therefore likely to have elevated his suicide risk.

The Coroner said the consequences of placing Heke in the unit, along with a lack of focused care targeting his underlying FASD condition, “were relevant factors in Tamaki’s death”.

The Coroner made no formal recommendations, noting that Waitematā DHB recognised in hindsight that Heke had been in the wrong facility for his needs.

His death highlighted the need for better resourcing for FASD sufferers.

Health New Zealand Waitematā had upgraded policies since Heke’s death to ensure family concerns triggered an immediate escalation in care and full risk assessment.

Peter Willcox told the Herald his son had few options due to a lack of support and lack of government funding for FASD due to the condition being treated as a “behavioural problem”.

While the unit had been the wrong place for Heke, Willcox agreed there was nowhere else for him to go.

“We couldn’t continue without support. We just couldn’t protect him or the community.”

Willcox said FASD was a “hidden problem” that was being ignored by the Government due to financial concerns, but this was risking the lives of people like his son.

A Te Whatu Ora spokesman said Heke’s tragic death had a devastating impact on his loved ones and staff who cared for him.

“We accept the Coroner’s findings and again extend our sincere condolences and thoughts to everyone involved.”

The death was fully investigated by an expert independent panel, resulting in policy changes – as acknowledged in the Coroner’s report.