A Coroner has ruled the ADHB could have acted quicker when Samara took off and her death 'would not have occurred'. Photo / Facebook
A Coroner has ruled the ADHB could have acted quicker when Samara took off and her death 'would not have occurred'. Photo / Facebook
Auckland Hospital “failed” mental health inpatient Samara Jade Visser and her family say she never should have been allowed out of the ward if they could not assure her safety.
Visser, 31, died in June 2019 after she ran away from a nurse on a walk during supervised leave from the hospital.
Earlier that day she had been assessed by a doctor and was “having bad thoughts” - but was still allowed out of the unit.
After Visser took off hospital staff initiated AWOL patient protocols but did not place her in a serious enough category meaning there was an 18-hour delay in police starting an active search for her.
Her sister Joy Kiwi told the Herald the family were still reeling from Visser’s death.
“All I know is she shouldn’t have been let out for that visit if they weren’t able to assure her safety in the community,” she said.
“We do not believe ADHB did their job to keep her safe and failed.
“They knew Samara and what she was like… Why allow someone to go out on leave with the nurse when they have shown to be previously suicidal and still hearing voices in her head?
“Why send someone out with a nurse when they are still hearing voices?
“The staff members told us they are not allowed to put hands on patients in the community, so why did they take her out knowing they cannot retrain her in any way if she were to escape?”
Samara Jade Visser. Photo / Facebook
Kiwi said Coroner’s report revealed there was a moment where her sister stopped briefly to speak to the nurse and tell her she just wanted to be “free”.
“In that moment she should have been held or at least physically manhandled to go back,” she said.
“If I was there I would have physically dragged her back to the unit knowing how impulsive she was at that time and especially her vulnerable mental state, listening to these voices in her head.
“My sister was unwell and should not have been taken out with someone who was unable to put their hands on her in the community.
“She had been in and out of the intensive care unit due to her behaviours of self-harm. Why then let her out with a staff member that cannot guarantee her safety?”
Kiwi said her family were told at a meeting with hospital staff after Visser died that it was not the first time she had absconded.
“The first time they were able to convince her to go back to the unit,” she said.
“Maybe they just were like ‘oh this is just Samara’ and didn’t think about what she was capable of - but she had shown that this was not her first time to run away.”
Ambulance at Auckland City Hospital. Photo / Jason Oxenham
Kiwi wanted people to remember Visser for “the beautiful person she was” and not just her mental illness.
“She had an outgoing, caring, bubbly and loud personality,” she said.
“Everyone she came in contact with loved her and she was the most generous person you ever met - usually too generous in my opinion).
“She was an amazing mother and wanted nothing but the best for her son.”
Visser grew up with her mother and did not see her father much during her childhood and teenage years.
She tracked him and her half-siblings down in her 20s and Kiwi said they became close.
Seeing her so unwell and struggling with her mental illness was “hard on everyone” but Kiwi said they all tried to support Visser as best they could and get her the help she needed.
“Her death has left a gaping hole in our hearts that will never be able to be filled again,” Kiwi told the Herald.
“All we can do is cherish the memories we have of her and who she was as a person.”
She said the Coroner’s report - a harrowing 15-page document - was welcomed by Visser’s family.
“I think it was very thorough and glad to see the Coroner was able to identify the problem in her management,” she said.
Samara Jade Visser died after absconding while on a walk with a nurse outside an Auckland mental health unit. A Coroner has released findings on the case. Photo / Facebook
Kiwi said she only wanted one thing to happen going forward.
“For [mental health] staff to actually follow protocols and have clear lines of communication with services and families to prevent incidents happening like this,” she said.
“I hope they take responsibility… and change the way they do things because it clearly did not work - and at the expense of my sister.”
“Our souls are connected… love and miss you forever.”
In her formal findings, Coroner Tania Tetitaha’s ruled there were “failures in the immediacy of the response by the ADHB” which led to Visser “avoiding detection”.
“If she had been immediately found and returned to the ward, this death would not have occurred,” she said.
“She was vulnerable and possibly medically non-compliant at the time she absconded.
Samara - described as a 'beautiful soul' - is survived by her son. Photo / Facebook
“There were risk factors for suicide in the circumstances leading to this death…Ms Visser had an extensive mental health history including a diagnosis of bipolar disorder.
“It is likely Ms Visser’s bipolar disorder contributed to her mood and decision-making leading to this death.”
Te Whatu Ora Te Toka Tumai Auckland interim lead Mike Shepherd could not comment on the specifics of VIsser’s care for “ethical and privacy reasons”.
“On behalf of our mental health service we would like to say how sorry we are for what happened to Ms Visser,’ he said.
“We acknowledge the loss and grief Ms Visser’s whānau will have experienced and express our sincere condolences to her whānau.
Shepherd acknowledged the Coroner’s findings and said the mental health team had “fully implemented all the recommendations”.
“Patient safety and quality of care is our top priority and, as always, we encourage whānau to talk to us directly if they have questions about their loved one’s care.”
Te Whatu Ora Te Toka Tumai Auckland had no further comment to make.
