KEY POINTS:
In his practice, he regularly faces the frustrations of getting patients referred. He's faced the frustrations of the system as a parent, too. And the tragedy of his talented, high-achieving, 22-year-old son taking his own life while under the watch of Auckland community mental healthcare.
"I take the view that my son's death was completely preventable," says the Auckland GP, who spoke to the Weekend Herald on condition he wouldn't be named - a restriction he says is not to protect him, but his family still coming to terms with their loss.
Like many, he sees mental health as the Cinderella of health services but believes, with a simple change of policies and attitudes, many lives lost through suicide could be saved: "My estimation is that 250 people would survive per year."
The problems begin with admission: "If I have a patient come in with a life-threatening illness and in need of urgent hospital assessment, I ring the doctor on call and 99 per cent of the time they will be admitted."
Compare that with getting someone who says he or she is suicidal admitted to a mental health service. "We can't speak to a doctor. We have to fax a letter and then someone from the crisis team will telephone the patient at home - sometimes hours later."
As a doctor, he's horrified that the patient isn't seen face-to-face and doesn't believe an adequate assessment of someone's mental state can be made over the phone.
"Why is it that a GP's opinion as to the need for hospital assessment is acceptable for other illnesses but not with mental health?"
Then there's the lack of resources, especially in trained staff to provide talk therapy and in places to provide respite care. "My son was putting his hand up for help. They didn't take that seriously and reached too quickly for the prescription pad."
Mindful of the pressures health services face, he was sympathetic to the difficulties his son's mental health provider was under - a position, in hindsight, he wished he hadn't taken.
"I should have been beating the drum. My son was seeking refuge from his many demands, a sanctuary which he didn't get."
The doctor also followed medical council guidelines about not treating his own family. "I stood off and very much regret that now."
The lack of empathy for mental illness shocked him to. "At Auckland A&E we were made to feel our son was not a sick person - that he had just taken an overdose and just been a silly boy. We left without being spoken to by a doctor. We felt guilty - that we had imposed on these people."
He says communication and the exercise of the Privacy Act are different in mental health services.
"If one of my patients goes to the emergency department of a hospital, I have all the details in my inbox the next day. If they are seen by mental health services, we are lucky to be posted or faxed information over the next couple of weeks."
Critical information was withheld from them, too - information which may have made a huge difference to their approach. Had his son broken his spine or contracted pneumonia, he knows disclosure of such information would not have been a problem.
It was difficult to make sense, too, of the practice of the psychiatrist seeing his son with a psychiatric nurse present, usually a different one each time, while family members were discouraged. As a doctor, he fails to see how a rapport can be established with a third person in the room, and why those who love and care for the patient the most are kept out.
Unlike other health services in the hospital, mental health services keep their records separate and not accessible to other doctors.
"That's like a prejudice. We're treating these illnesses differently - as though you have got something you are ashamed of. Mental health services actually support discrimination by their secretiveness."
Nowhere was the difference between healthcare systems more marked than when his son died.
"He died in intensive care. During that time we had fantastic care and there was no expense spared - everyone talked to us openly about our son and there was no question about the Privacy Act. Why do we get such superb care when he's dying and minimal care when his illness is being treated?"
A COMMON theme among cases researched by the Weekend Herald is the disregard given to parental or family concerns.
"The rights of parents to make decisions regarding their child's care is blocked at every turn by the ideal that every individual, even those with mental health issues, should be able to make decisions on their own behalf," Sally Fisher told the coroner's inquest into her son's death.
Maria Bradshaw, Toran Henry's mother, was ignored when she objected to her son being prescribed Prozac. Toran died in March. A review into Toran's care was critical of the Marinoto Mental Health Service registrar who prescribed the drug, saying "his interaction with Toran's mother was unduly paternalistic".
It was critical, too, of the registrar's advice that Toran need not take Prozac on the days he drank alcohol. "This advice does not make pharmacological sense and could have further reduced the effectiveness of the antidepressant."
The review questioned why Toran was given Prozac in the first place - noting that there was no clear diagnosis of depression and that his mother had requested the service try a psychological approach first. Bradshaw is angry that her son was not warned about the possible side effects of Prozac - that it can increase the risk of suicide in persons younger than 25.
The report indicates also that Toran wasn't properly monitored for adverse reactions to the drug, despite his mother reporting he became aggressive and agitated when using Prozac.
Bradshaw, like Fisher, is calling for an independent inquiry into mental health services - in her case, particularly for adolescents. Like Fisher, she is also frustrated by policies and attitudes that prevent parents being heard.
Toran's case was frequently mentioned during a panel discussion at a Suicide Prevention Information New Zealand (Spinz, part of the Mental health Foundation) seminar on the role of media in suicide prevention, in September. Many hadn't realised Bradshaw was there.
"I'm Toran Henry's mother. Toran Henry is the person you have been referring to all day as the North Shore incident, or the North Shore case," she told a surprised audience.
Toran's death received widespread media coverage, much of it in breach of the Coroners Act which prohibits calling a death suicide until an inquest is completed. Media organisations deal with restriction by using code words - "tragic", "sudden" or "referred to the coroner" - as a reference to suicide in their reporting.
But in Toran's case, information came via his mother and friends, resulting in more explicit wording: "arriving home to find him lifeless" and "found dead by his mother". Some media organisations went further, baldly reporting on the self-inflicted nature of the death and its location.
Bradshaw argues if it hadn't been for media coverage, there would never have been inquiries into her son's death - to date there have been three: by Takapuna Grammar, the school Toran attended, by Marinoto and by the Education Review Office. The police investigation and coroner's inquest are still to be completed.
The Takapuna Grammar inquiry, conducted by Sir Ian Barker, QC, found the school "acted in good faith and according to its best lights towards Toran".
The retired senior judge of the High Court did, however, recommend that "special and sympathetic attention" be paid to students where a student's serious mental health condition is known. And that "prudent dissemination of this knowledge" would assist teachers.
"Teachers could be told confidentially, for example, that a student was being treated for depression." Barker concluded: "Society must strive to look after its weakest members. One wonders whether anything else the school could have done would have much difference to this young man."
For several months after Toran's death, Bradshaw was involved in a website dedicated to her son. Many of the posts on the site were outpourings of grief, but there was also quite detailed discussion about Toran's death and reactions from his friends - many also in clear breach of the Coroners Act.
The site was also instrumental in organising a protest march up Queen St on May 13, the day Toran would have turned 18.
The website (since removed by Bradshaw) and the protest march fly in the face of in the face of Ministry of Health guidelines on dealing with suicide and its reporting. But Bradshaw is unrepentant.
A week ago as a guest speaker at the opening of an exhibition at the Parent and Child Show at the Epsom showgrounds, she told the audience: "I've breached the Coroners Act so many times I don't care. There is nothing I have to lose any more and nothing I won't do to have the truth told about my child."
The concern, and the thinking behind the Coroners Act restrictions, is that sensational reporting about suicide has a contagion effect that puts others at risk of copycat suicides - evidence for which comes from overseas research.
Examples include a 17 per cent increase in self-poisoning a week after British television drama Casualty broadcast an episode about suicide, which gave information about a particular drug.
And, following a 1998 story in Hong Kong which detailed a new method of suicide, the technique spread throughout the region. Other studies show increases in suicide rates linked to front-page news stories and reportage about celebrity suicides.
What the Ministry of Health and organisations like Spinz want to avoid is sensational reporting with simplistic explanations of the cause of death, overly graphic details (such as the location of where the death occurred) and photos of shrines and people memorialising the death.
"These are profoundly unhelpful," says says Merryn Statham, director of Spinz, who was concerned about Toran's website at the time, plus some of the social networking sites such as Bebo, used by Toran's friends.
Such sites, to the adolescent way of viewing the world, she says, memorialise and create a point of identification for other young people.
"If a young person takes their life, then receives a lot of outpouring of love, adulation and respect of an enormous number of people in a highly public way, other young vulnerable people who are looking for a way to have love, respect and adulation would see that as an attractive option."
Bradshaw disagrees. She says her key concern since Toran's death has been the wellbeing of his friends and her doctor's advice was that seeing the impact on her was "the best suicide prevention education these children could ever receive".
Then there is the issue of the T-shirts - with a picture of Toran on the front. Many of Toran's friends wore these to his funeral and then to school for a few days after. They were also worn for the Queen St march. The back of some of the T-Shirts and on some of the banners at the march had the letters FTW. It stands for "F*** the World".
The problem Spinz has with memorialising in relation to suicide is that it can stray into glorification. Statham says careful negotiation is needed to find another way to achieve the same purpose - an alternative to wearing a T-shirt with their friend's photo on it to show him respect.
No longer permitted to wear the T-shirts to school, some of Toran's friends had tattoos done in his memory. Others wore wristbands with "Toran Henry" on one side and "FTW" on the other. In the age of the internet, trying to control how people grieve and what they can, or can't say, seems an impossible task.
The counter-argument is that the Coroners Act and moral panic about the contagion effect, imposes what has been called a "tyranny of silence" and a "veil of secrecy" on suicide. The word is taboo at schools, which follow their "traumatic incident response policy (TRIPs)" when one occurs.
"Best practice" advice is not to make an announcement at an assembly, but to do it at form class level - and even then, not mention the word suicide, but to advise students that there has been a death and what counselling services are available. Best practice also means the topic is off-limits in subjects such as drama, English, media studies and photography.
It's a silence that seems disconnected from reality. Immediately after Toran's death, most of the students at Takapuna Grammar knew exactly what type of death had occurred and many were talking in detail about how and why.
Small wonder that a day after the funeral, a large number of students gathered on a sports field at lunchtime to listen to music, perform a haka and light up cigarettes in memory of Toran. They, and Toran's mother, wanted to be heard.
"We talk about safe ways to talk about suicide," says Statham. "The issue is not 'don't talk about it', it's [about] how it's best done."
Hence the focus on individual counselling sessions which stress key messages: Always ask someone for help; look out for others who may be at risk; and that personal problems, no matter how big they seem, can always be solved.
Best practice also includes messages to parents, usually via a meeting at the school, advising what to expect, what to watch out for and who has the expertise to help.
But it's clear from Toran's website and the protest march, that best practice doesn't always work. That in the face of containment and control, grief will cut its own channel.
It's clear too, from the actions of people like Bradshaw and Fisher, that some think there is much more about suicide that needs to be said. How, in the face of taboos about talking about methods or locations of suicide, do young people learn about the dangers of experimenting, and how quickly in some circumstances death can occur?
And how else, but by talking about them, will problems in our mental health services be brought into the open? Domestic violence, incest and child abuse were once also shrouded in secrecy. How long before we make the victims of suicide - 511 in the year to June - visible?
SYSTEM FAILURES
"Mental illness is like obesity. It's the other burgeoning illness and one of our biggest killers," says an Auckland GP in support of a petition calling for an inquiry in mental health services. The petition was organised by Sally Fisher, Donna Moore and others who have lost family members to suicide.
In the inquest into Shane Fisher's suicide, Fisher pointed to the widespread problem of "system failures" and how engaging with mental health is an exercise in frustration.
Much of what she says is born out by others. At Shane's inquest, evidence from the Allied Health Public Service Association about Te Whetu Tawera, the Auckland mental health unit responsible for Shane's care, outlined several issues including: * A unwritten tenet that short admissions were an indicator of competent practice and lengthy admissions the reverse. The association argued a notional average length of stay had nothing to do with how a person should be treated.
* That "bed pressure" is caused by a lack of readily available discharge options and that people can remain in the unit for over 12 months because it is not possible to discharge them.
* The current system requiring referral to a needs assessment service is flawed because it duplicates clinical staff actions. * The system copes by discharging the least unwell person to allow for the next admission, increasing the likelihood of adverse outcomes.
The unit was also heavily criticised by an earlier external review. Four cases were under scrutiny: * a man alleged to have committed homicide following discharge * a man committed suicide in an open ward * a patient died during the night following admission to intensive care * a man who apparently committed suicide in intensive care. The review team said these cases, plus two others, showed evidence of "unacceptably poor clinical judgment and practice by some medical and nursing staff."
The ADHB has taken steps to remedy some of the failings and in its response made reference to the recovery model focus of mental health care. On risk assessment, which Fisher argues was a key factor in her son's death, the board noted "risk assessment process and documentation have not been consistently utilised". It has since changed its clinical information system.
The unit isn't alone in its failings. Other instances this year include: * A review of Canterbury DHB's acute services at Hillmorton Hospital which identified "significant areas for improvement."
* Officials apologising to the family of social worker Brenda Moore, found dead in the grounds of the Henry Bennett Centre at Waikato Hospital. * Capital and Coast District Health apologising to the family of Janine Fraser, who died after being sent home from a respite house.
* Lifeline: 0800 543 354 (www.lifeline.co.nz)
* Youthline: 0800 376 633 (www.youthline.co.nz)
* Depression Helpline: 0800 111 757
* In an emergency (if you feel you or others are at risk of harm) phone 111
* Or contact a doctor or your local mental health crisis service (see the medical section at the front of the phone book, or phone Healthline on 0800 611 116)
* Further information: Suicide Prevention Information New Zealand (SPINZ) - www.spinz.org.nz.
