Father of one Shaun Gray died of a suspected suicide in 2014. Photo/Supplied.
Father of one Shaun Gray died of a suspected suicide in 2014. Photo/Supplied.
"I wasn't told about his suicide risk," a nurse has told a coronial inquest into the suspected suicide of a man at a mental health ward in 2014.
Shaun Gray was found dead in his room roughly 12 hours after he was admitted to Palmerston North Hospital's Ward 21 more than eight years ago.
Months after his death, Erica Hume, 21,also died of a suspected suicide at the ward.
It's the fourth day of a three-week inquest into Gray's death in which coroner Matthew Bates is seeking to establish if his death could have been avoided, and how to prevent more patients meeting a similar fate.
On the first day of the inquest, Gray's care worker at the Alcohol and Other Drug service, which managed his daily dose of methadone, told the court it was a fight to get him admitted into the High Needs Unit of the ward.
The day before he was admitted he had taken a range of barbiturates and injected himself with acid and was taken to the Emergency Department.
The care worker said she'd tried to convey he was a suicide risk when she arrived at Ward 21 ahead of Gray, but felt the staff weren't listening.
"The handover felt like a fight. I was on my own at the nursing station with a doctor arguing with me about whether she would accept Shaun and a nurse that would not listen to me," she said.
"I had no assistance. At one point I thought they were going to refuse his admission.
"I continued to try and talk to the nurse and give a verbal handover.
"She appeared very distracted - I asked her at one point 'Are you even listening to me?'."
Today, that nurse had a chance to respond to those claims before the inquest.
"It wasn't that I wasn't listening," she said.
"She was talking to the doctor, I was expecting to receive a direct handover nurse to nurse, which has occurred on every other occasion. I didn't really feel a part of that conversation.
"A verbal handover did occur but it was sparse."
The nurse said she was aware that Gray had tried to end his life the previous day from having read his file, but she did not complete a patient admission form before handing over to her colleague around 3pm on April 16.
"I do remember telling her that he had overdosed and that he'd injected substances," she said.
Father of one Shaun Gray died of a suspected suicide in 2014. Photo/Supplied.
"In hindsight I didn't even really think about him being suicidal so how was I going to say it, it wasn't something I was thinking about.
"When I was nursing him I wasn't concerned he was going to harm himself."
She said she did not record whether or not she had reviewed Gray's risk assessment form, but her focus had been on trying to settle him down.
The facts
According to the summary of facts, on the morning of April 15, 2014, Gray became agitated after being denied a take-away dose of methadone from his local pharmacy.
He called his care worker in a state of agitation and then sent a text to his mother - who then also called the Alcohol and Other Drug treatment centre in Palmerston North.
A plan was then made to collect Gray and bring him to the centre. However, when staff picked him up he told them he'd taken a range of barbiturates and injected himself with acid.
They took him straight to hospital where he was refusing treatment and was aggressive towards staff and expressed suicidal tendencies.
The next day he was transferred to the High Needs Unit in Ward 21 at Palmerston North Hospital.
Shaun Gray died at Palmerston North Hospital's mental health ward on April 16, 2014. Photo/Supplied
Later that evening, just before midnight he was found unresponsive in his room.
Scope of the inquest
As part of the inquest, coroner Bates is seeking answers to pages of questions in relation to Gray's death.
Among those are whether the cocktail of drugs Gray was prescribed contributed to his suicidal tendencies and why the nurse charged with his care at Ward 21 did not convey his suicide risk in her clinical notes.
Photos from the rooms inside Ward 21 during the Ombudsman's surprise inspection in May last year. Photo/ Privacy Commission
Also under scrutiny is the staffing level at the ward, which was found at the time to be suboptimal as well as the frequency to which Gray was checked on during his brief stint there.
The coroner will try to establish what has changed at the ward since Gray's death.
In May last year, Chief Ombudsman Peter Boshier paid a surprise visit to the infamous ward and released a report describing it as one of the worst in the country.
The inquest is set to call a further 23 witnesses over the next few weeks.
