Grant Trillo died in Christchurch Hospital in 2022. Photo / RNZ
WARNING: This article discusses suicide and may be upsetting to some readers.
When a man was picked up by police at a domestic airport, threatening to take his life, officers took him to a hospital but did not mention his concerning mental health.
Four hours later, he was dead in a hospital room.
Now, the coroner who investigated the death of Grant Trillo, 51, has found it could have been avoided had police passed on that vital information.
Coroner Mary-Anne Borrowdale made a comparison in her findings, publicly released today, to the death of Jonas Rika, who in 2016 was returned to a hospital by police with no mention of the self-harming statements he had publicly made.
“In both cases, constables who were aware that the patient had expressed a wish to die did not pass that information along to medical personnel when handing over the patient.”
The findings detailed how Trillo, of Whanganui, was involved in a motorcycle accident in 2015, leaving him paralysed from the chest down, and although he had some issues with depression, he had never threatened to end his life.
For the next few years, Trillo reportedly struggled with his lack of independence and had multiple bouts of aggression toward medical staff.
After trialling multiple pain relief medications, Trillo had an abdominal intrathecal baclofen pump (ITB) installed to deliver medication directly into the spinal fluid.
The pump was installed on November 24, 2022, and he was discharged in a positive mood.
But on December 14, Dr Juriaan de Groot conducted a home visit and found Trillo in a highly agitated state, with his mother reporting he had been ramming his wheelchair into doors and walls.
Trillo, who was reportedly in a delirious state with inflammatory markers, was transferred to Christchurch Hospital and was admitted to the neurosurgery progressive care unit (NPCU).
He was assessed as having pneumonia and no flags were raised around a risk of depression.
For the next two days, Trillo was verbally abusive to staff, smoking in his room and said he felt like he was being held captive.
On December 17, Trillo left the hospital in his wheelchair, with his catheter, and made his way to Christchurch Airport.
Around 10.30am, Air New Zealand staff called the ward and told them Trillo was trying to book a flight to Whanganui.
When Constable Gina-Marie Cain and Constable Matthew Casper arrived to assist, they were advised Trillo had made a threat to kill himself if he was not allowed on the flight.
The officers logged a 1x job in the police system, that being the code for suicide, and assisted in his return to the hospital around 11.45am.
Police did not communicate anything to ward staff about Trillo having threatened to take his life if he was not allowed to fly.
“I did not advise staff at Ward B8 of Mr Trillo’s comments of threatening to harm himself if he could not get on a flight. My assessment at the time was Mr Trillo had made the comments in the hope of getting on a flight,” Casper told the inquiry.
“During my short dealings with Mr Trillo, he gave me no indication that he actually intended to harm himself.”
Cain did not explain why she had not mentioned the suicide threat to the ward.
Back in the ward, Trillo was resistant and abusive to the medical staff.
Neurosurgical registrar Dr Alexandria Marino asked the psychiatric crisis resolution team for advice but was told Trillo was not deemed a risk of harm to himself.
For the next few hours, his aggression continued and despite regular 15-minute checks, at 3.45pm Trillo was found dead in his bed.
Police told the coroner it was accepted and acknowledged there was a failure of action.
They said that since the incident, significant changes have been implemented in how they respond to those in mental distress.
This included guidelines around officers’ responsibilities when they brought a patient to a hospital Emergency Department, discussing the case on meeting the triage nurse and sharing full event details, including any risk assessments.
However, with a recent law change requiring police to hand over those in crisis within 15 minutes, the coroner expressed her concerns.
“We are therefore now in a time of far-reaching change in how police respond to persons in mental distress,” Coroner Borrowdale said.
“Police expect there to be a reduction in their involvement with mental health transports and a reduction in police responses to health sector requests that do not involve an immediate risk to life and safety.
“But this means that I cannot feel reassured that a police handover to a ward – as opposed to an emergency department – would be handled differently today.”
Coroner Borrowdale was also critical that local officers advised they had a learning debrief after the incident.
“I do not consider it a sufficient response to this tragedy that the police have had a learning debrief with the officers concerned, local Canterbury rural area team staff, and have ‘recorded it as a lesson learned’. These events, and the learnings to be taken from them, deserve a much larger audience within the community of frontline police staff.”
The coroner recommended that police fully inform the receiving party of any suicide risk, ensuring they take appropriate precautions and seek clinical intervention.
Additionally, she advised that this case be included in nationwide training for frontline staff on managing suicide risks.
“This death may have been prevented if this vital information about the risk of self-harm had been passed by police to hospital staff.”
Although Coroner Borrowdale ruled Trillo died by suicide, his family do not accept he intended to end his life.
Shannon Pitman is a Whangārei-based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.
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