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Shaun Gray took his own life after being admitted to Palmerston North Hospital’s mental health unit ‘Ward 21′ in 2014.
Now Coroner Matthew Bates has found multiple failures in Gray’s care saying the ward is ‘not fit for purpose’, and his death ‘was avoidable and should have been prevented’.
He has also found Gray was being given too much methadone - a drug used to help treat recovering opioid addicts - before his death.
WARNING: This story is about suicide
Despite “alarm bells” being raised about an American psychiatrist prescribing “imminently unsafe” high doses of drugs to recovering addicts, nothing was done to adequately supervise Dr Sarz Maxwell.
This was one of several failures identified by a coroner over the care of 30-year-old Shaun Gray, who took his own life in April 2014, soon after being admitted to Ward 21, the mental health unit at Palmerston North Hospital.
A month later, 21-year-old student Erica Hume died at the same unit, which has since been labelled “not fit for purpose” and a third person died at the ward in 2021.
A coroner has found in a report on Shaun Gray's death that Palmerston North Hospital's mental health unit is not fit for purpose.
Today, Coroner Matthew Bates released his findings into Gray’s death after holding almost back-to-back inquests in Palmerston North in 2022 to explore the surrounding circumstances of both deaths.
While Gray’s family say they’re relieved to finally receive the findings, their journey has been long and painful.
“One sentence in the Coroner’s report stands out to us: ‘I find that Shaun’s death was avoidable and should have been prevented’,” his family said in a statement to NZME.
“This statement is the heart of our grief and frustration. The evidence clearly indicates that the failings leading to Shaun’s death were both preventable and a result of gross negligence.”
The family said they would continue to seek justice for Gray.
“This is not just about Shaun—it is about a system that must be held accountable for the lives it is meant to protect."
Methadone script outside the realm of accepted levels
A key focus of his findings was that Gray was being given too much methadone - a drug used to help treat recovering opioid addicts, by his psychiatrist, Maxwell, in the lead-up to his death. He was not in the care of Ward 21 at this stage.
“Dr Maxwell’s methadone prescribing practices were significantly outside the realm of accepted usual prescribing practice in New Zealand,” Coroner Bates said in his findings.
“Under Dr Maxwell’s care, Shaun was prescribed methadone at levels significantly higher than what is clinically recommended for addiction treatment in New Zealand. Shaun’s case was not an outlier.”
Gray was receiving nearly three times the standard dose of methadone, and a later review of Maxwell’s prescriptions found that 30 of her 40 patients were receiving 150mg per day, while the remainder received in excess of 300mg.
Dr Sarz Maxwell. Photo / Supplied
Medsafe recommends doses of between 35-50mg and a maximum of 80mg.
Speaking from Chicago where she now works, Maxwell told NZME she stands by her dosages.
“The outcome of my patients was uniformly better than any of the other doctors. But when I brought that up, when I said all the patients improved I was told that’s not the point,” she said.
“I thought patient improvement was the point of medical care?”
When asked, Maxwell said she did not feel personally responsible for Gray’s death.
“He was very sick, I did my best for him, he did his best and it wasn’t enough.”
One medical specialist found that Maxwell’s prescribing practise was “imminently unsafe” and was “contributing to street availability of abusable pharmaceuticals”.
The chief medical officer at the DHB at the time said there were “alarm bells” with Maxwell’s application, but felt those concerns could have been managed with supervision.
However, Coroner Bates said that didn’t happen and her immediate supervisor was neither an addiction specialist nor did he know concerns had been raised about the levels she was prescribing at.
Doctors who are recruited from overseas are now required to be under the supervision of a senior medical office with the same speciality.
The Gray family said they were “appalled” that Maxwell was allowed to practise in New Zealand.
‘Shaun had the means and opportunity to end his own life’
Coroner Bates said Gray’s death “was avoidable and should have been prevented”.
Bates also found that Palmerston North’s now infamous Ward 21 mental health unit was not fit for purpose.
“All available steps should be taken to ensure the new inpatient facility currently under construction opens as soon as possible, to ensure mental health service users in the region can receive the best available care in a much safer environment than the current Ward 21,” Bates notes in his 214 page decision.
Father-of-one Shaun Gray died by suicide in 2014. Photo/Supplied.
Some of the failures Bates identified at the ward included poor communication among staff, a failure to review key documents about Gray’s risk of suicide, inadequate documentation and the fact that Gray should have been checked every 10 minutes - but was left unsupervised for over an hour.
“The combined impact of the failings described was that Shaun had the means and opportunity to end his own life.”
According to the summary of facts, on the morning of April 15, 2014, Gray went to his local pharmacy to be given his daily medication of methadone.
After not being allowed to take this medication away with him he became agitated and called his care worker. He then sent a text to his mother. She called the alcohol and drug treatment centre and explained her concerns.
A plan was then made to collect Gray and bring him to the drug and alcohol treatment 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 the hospital where he refused treatment and was aggressive towards staff.
He expressed suicidal tendencies and a call was made to keep him in hospital under restraints.
He was transferred to the High Needs Unit in Ward 21 the next day.
Erica Hume died at the same unit a month after Gray. Photo / Supplied
While there the nurse who was originally charged with his care did not complete his admission documentation before her shift handover.
There was also some confusion about the prescription of an abnormally high dose of medication to help Gray sleep. His doctor was called and the dose was lowered.
However, Gray did not consume any of his sleep medication that night.
Just before midnight he was found unresponsive in his room.
‘Stretched thin’
Coroner Bates made a litany of findings in regard to failings in Gray’s care that were made in the hope of reducing the chance of further deaths in similar circumstances.
The coroner said a combination of factors contributed to Gray’s death including frustration at not being allowed takeaway methadone, distress upon learning he would be admitted to the high needs unit instead of the open side of Ward 21, frustration at incorrect doses of medication offered to him in HNU, and various other personal issues he was experiencing.
There was also poor communication between staff upon Gray’s admission to the ward and the admitting nurse did not document that he was at high risk of self-harming.
Coroner Matthew Bates. Photo / Jeremy Wilkinson
“This broke the chain of vital information which should have been known by Ward 21 staff.”
Coroner Bates said that the policies and procedures at the high needs unit were adequate but “it was the failure by management and other staff to ensure those policies and procedures were adhered to which resulted in Shaun receiving substandard care, and which ultimately enabled him to take his own life”.
Gray did not receive a psychiatric assessment after his admission to Ward 21 because he was highly agitated at the time, however, there are no notes from the psychiatrist to reflect this.
“Psychiatric assessment of Shaun following his admission may have alerted nursing staff to Shaun’s suicidal ideation and the risk.”
Staffing levels were “stretched thin” on Ward 21 and there were numerous unfilled vacancies. It was not uncommon for nurses to work back-to-back shifts. On the night Gray died two nurses at the unit had worked double shifts.
Gray was also not checked on for over an hour, though policy at the ward was to not leave high risk patients unobserved for more than 10 minutes.
The Gray family say they have requested that a nurse, who has suppression, who failed to check on Gray be investigated by police and by the Nursing Council.
Coroner Bates also found there were gaps in nurse training and no audit system in place at the time to verify staff knew the policies and procedures at the unit.
An internal review of the unit was conducted several months after Gray’s death and found many of the same issues Bates did in his findings.
An external review was also commissioned and made similar recommendations, and a series of changes to the way the unit operated.
However, eight years later and one month before the inquest into Gray’s death 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 roof of the new mental health unit at Palmerston North Regional Hospital was completed in May 2024. Photo / NZME
He found that the 24-bed ward was over capacity. Māori were put into seclusion at higher rates and there was urgent repair work needed.
Boshier also found there were a high number of medication errors, young people were often restrained and their access to telephones and leisure activities was limited.
A new $35 million ward was announced by the Government several years ago and was due to open in 2022, however, that opening date was pushed back to 2023, and is now expected to open later this year.
The Gray family said they had never been consulted or involved with the planning of the new ward and felt it was nothing more than a photo opportunity for the Prime Minister and health executives.
“The only involvement we wish to have is when the current Ward 21 is demolished,” the family said.
“The fact that millions of taxpayer dollars were wasted on this ward is a clear example of systemic failure.”
‘We are sorry’: Significant changes have been made
Dr Claire Hardie, the chief medical officer at MidCentral DHB, said the Health New Zealand recognised the profound impact Gray’s death had on his family, and acknowledged there had been other deaths at the unit.
“We acknowledge and will carefully consider the coroner’s recommendations,” she said.
“Significant changes to our practice have been made following these tragic events to prevent them happening again.”
Hardie said that changes had been made to the hospital’s observation policy to better support high risk patients and had reviewed its admissions and handover practices to ensure that patient notes were handed over to new staff as they came on shift.
“We have also undertaken significant work to improve conditions and team culture for our staff. We have increased our staffing levels on Ward 21, including new leadership roles…” she said, also noting that the new ward was scheduled to open in August.
“We are sorry that these improvements in our system came too late to help Shaun and prevent the immense loss that Shaun’s family have experienced.”
Jeremy Wilkinson is an Open Justice reporter based in Manawatū covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.
