Nicola Peeperkoorn discusses the mental health and addiction event review process. Video / Te Tāhū Hauora Health Quality & Safety Commission
WARNING: This article discusses suicide, depression and mental health issues.
A family say they were “robbed” of the opportunity to help a 62-year-old loved one after they weren’t told about his deteriorating mental health by hospital staff before he was found dead near a swamp.
A coroner has found Allan Peeperkoorn’s death in 2019 was self-inflicted. It was also the third suicide in a month within the Waitematā District Health Board’s (DHB) catchment area.
Following those deaths, a damning review found poor leadership and staff burnout were factors at He Puna Wāiora in Takapuna and suggested the building’s physical design assisted patients in taking their own lives.
Two years before, Donald Morey committed suicide at another unit at North Shore Hospital with a coroner finding in 2022 that staff failed to carry out 10-minute observation checks on him, which allowed him a “window of opportunity” in which to kill himself.
Peeperkoorn was a patient at a different unit,Bodi Place, also run by the Waitematā DHB. Now, five years after his death, Coroner Katharine Greig has found that staff shortages coupled with poor communication with his family may have been a factor in his death.
“It cannot be known whether the outcome would have been different if Mr Peeperkoorn’s family had been included in his care by Waitematā DHB mental health services – but it could have been,” she said in a decision released today.
“I have formed the view that Mr Peeperkoorn was failed in this regard. He was deprived of the opportunity to have his family – who were providing loving general support and who he considered to be protective factors for him – included by mental health services as informed participants in his care and support as he became increasingly distressed.”
Peeperkoorn’s wife Ann told NZME that while she was glad the findings had finally been released she was cynical about how much would change.
She said families deserved to be involved in their loved ones’ mental health journeys and were a valuable resource and support network that shouldn’t be underestimated by clinicians.
“This whole thing of ‘we know best’ doesn’t always work,” she said.
“In his last week we had no idea how bad he was.
“There were so many flags that had we known we could have done something.”
A family man who worked to find solutions
His loved ones described Peeperkoorn as a family man who was a football “stalwart” and deeply involved in playing and then coaching the game.
They also described him as a committed union man “who would stand up for everyone’s rights” and was overall a man of action who worked to find solutions to issues.
Peeperkoorn first started developing issues with his mental health when he was 30 and began experiencing anxiety and depression and had engaged with Waitematā DHB’s mental health services periodically since 1998.
These issues, and alcohol dependence, became worse after he was made redundant from NZ Post in 2017.
Peeperkoorn was admitted to a detoxification unit for his alcohol dependence in 2018 where he responded well to sobriety and was keen to stay that way. However, by October of that year he was having severe ongoing anxiety and suicidal thoughts.
In April 2019, Peeperkoorn met with a psychiatrist about severe anxiety and was referred to a counsellor. Initially, it was thought he was responding well to those sessions as he remained sober and was keeping his anxiety in check.
However, the following month he called the mental health services team as he was having suicidal thoughts and did not feel safe. He went to the emergency department and said his anxiety had “shot through the roof” and he had been thinking about the method he would use to kill himself.
He was discharged later when he had calmed down and staff informed his wife and gave her details on how to get in touch if she had any concerns.
Mental health services continued to check in on Peeperkoorn over the next few weeks. In May, a psychiatrist diagnosed him with “agitated depression” coupled with co-morbid anxiety.
By June 9, Peeperkoorn told clinicians he was increasing his usage of the anxiety drug lorazepam.
The following day he phoned them, saying he was not feeling safe, before meeting with staff and signing a “commitment to life” contract to stay alive for the next two weeks.
That evening, staff offered him a place in respite care, which Peeperkoorn declined as he felt safe with his wife at home and was keeping busy.
The following afternoon, Peeperkoorn met with staff and discussed the method he would use to kill himself and told them he had been making preparations, including writing a suicide note. He again declined a respite care bed for the evening.
On June 12, a bed became available at Bodi Place in Te Atatū – there were no beds available at a respite facility on the North Shore where Peeperkoorn lived – and he packed a bag and drove himself there, planning to stay for two days.
Bodi Place had no registered nurses on staff and patients attended voluntarily and could come and go as they pleased.
Peeperkoorn woke the following morning with the shakes, trouble breathing and heightened anxiety. However, a doctor who assessed him didn’t feel he had any intent to harm himself and had a good support network around him.
By June 15, he self-assessed his suicidal thoughts at being a 9.5 out of 10, though another doctor formed the view that his risk to self was significant but not imminent, and recommended he remain in respite care and discussed the possibility of moving to a more intensive unit in Ōrewa.
Unsuccessful attempts were made to contact Peeperkoorn’s wife and then he was taken back to Bodi Place but no handover was given to staff about his risk level.
Staff at Bodi Place contacted mental health services to clarify his medication and no update was given by them about his risk assessment earlier in the day. Peeperkoorn’s care at Bodi Place continued to be guided by the original management plan, albeit with changed medication.
Then at 1.30pm, Peeperkoorn told staff at Bodi Place he was going out for an hour, but by 6pm he had not returned for dinner. He also hadn’t gone home to his family on the North Shore.
Peeperkoorn’s daughter contacted mental health services and said she had spoken to her father when he telephoned home at about 4pm, trying to get hold of her mother. He said to her, “I am so glad to hear your voice”, and then the phone cut out.
Police began to search for Peeperkoorn that evening before finding his body at the edge of mangroves in an estuary near Bodi Place.
The coroner was satisfied on the evidence provided that Peeperkoorn had committed suicide and there were no suspicious circumstances.
Following Peeperkorn’s death, it was his family’s position that the Waitematā DHB had not communicated to them how serious his deteriorating mental health was.
Peeperkoorn’s daughter Nicola told the coroner that the family felt “robbed of the opportunity to help and support” her father and that staff had ignored his natural support system and lost a powerful ally in helping him as a result.
The coroner noted the record showed the family had not been informed of a referral to mental health services on May 27, nor of an assessment on June 11 where staff were concerned about his suicidal ideations.
“As Mr Peeperkoorn became increasingly anxious, it appears that no consideration was given by Waitematā DHB mental health services to discussion with his family before a decision to move Mr Peeperkoorn to respite care was made.”
Coroner Katherine Greig. Photo / Samuel Rillstone, RNZ
Following his death, an internal investigation found issues with the way Peeperkoorn’s care was communicated to his family.
“It is hard to escape the conclusion that although in Mr Peeperkoorn’s clinical records there are frequent references to him referring to his wife/family/grandchildren being protective factors for him, his care and treatment by Waitematā DHB mental health services occurred largely in isolation from them,” Coroner Greig said.
“The evidence is clear, as the internal investigation notes, that Mr Peeperkoorn’s family was not included in any meaningful way in his care.”
Coroner Greig said information was not provided to the Peeperkoorn family that might have helped them understand his treatment or changes in his condition.
Peeperkoorn raised frequently with clinicians that he did not want to be a burden on his family and Coroner Greig said this should have been a signal that he wasn’t keeping them informed about his increasing distress and anxiety.
“What Mr Peeperkoorn did and didn’t tell his family is a matter that became clear only after his death,” Coroner Greig said.
The internal investigation also found there were staff recruitment and retention issues within mental health services, meaning there was less face-to-face contact between clinicians and patients.
The same investigation found there were differences in the way different clinicians formulated management plans for Peeperkoorn as well as changes to his medication, and these were exacerbated by the staff shortages.
In addition, staff at Bodi Place received a “scanty” management plan for Peeperkoorn and there was little communication with the unit from the Waitematā DHB.
“It is not possible for me to say that had he received care of an appropriate standard Mr Peeperkoorn would not have died – however, it is difficult not to form the view that Waitematā DHB mental health services let Mr Peeperkoorn down in the last weeks of his life and he did not receive assessment and care that gave him the best opportunity to improve and work towards recovery,” the coroner said.
Peeperkoorn’s family maintain that he should have been admitted to the Mental Health Unit on June 15 after he’d told a doctor his suicidal thoughts were at a 9.5 out of 10.
“At this point, a Mental Health Unit admission would have offered a safer alternative to continuing in the respite facility, with trained staff on hand to observe and support Allan through his distress. It may have offered a window to delay his suicide attempt, if not stop it in the future,” his daughter told the coroner.
Coroner Greig found that with the benefit of hindsight, this option should have been considered more closely.
A tragic outcome
The coroner said it was unlikely Peeperkoorn would have died in June 2019 if he had not been left to his own devices.
“These findings identify a number of opportunities lost by the services caring for Mr Peeperkoorn to provide him with appropriate care, support and supervision at a time when he was becoming increasingly agitated, was feeling increasingly suicidal and was increasingly vulnerable.
“This finding highlights concerning systems failures in a stressed acute mental health service, lack of continuity of care, inadequate communication, some questionable clinical judgment decisions and lack of family involvement.”
Since Peeperkoorn’s death, the trust that operates Bodi Place has appointed a clinical nurse manager responsible for all referrals to the unit, has reviewed its reporting systems and has regular meetings with mental health services from the DHB.
The Waitematā DHB internal investigation also made a series of recommendations including training for new staff on risk assessments and family engagement and standardising communication between differing sectors of the DHB.
However, an update to these changes to the coroner noted there were still significant staffing shortages within mental health services and the unit that dealt with Peeperkorn’s care was down by 12 staff members as at July 2024.
The coroner recommended a copy of her ruling be provided to Health New Zealand Te Whatu Ora so it can understand the consequences of Peeperkorn’s family not being involved in his care.
Coroner Greig also recommended Health New Zealand and the organisations it works with have a system to ensure referrals from adult mental health services are processed correctly, clients are reviewed daily by an appropriate standard and any contractor is able to contact Waitematā Acute Adult Mental Health Services if concerned about a client at any time of the day or night.
Health NZ’s acting clinical director, specialist mental health and addiction services at Waitematā, Dr Aram Kim, said in a statement to NZME that the agency was sorry for what happened to Peeperkoorn, and to his family.
“When there is a tragic outcome involving a service user in our care, we take this very seriously and undertake an investigation of the care and treatment provided,” Kim said.
“The aim of this process is to fully understand what happened and reduce the chance of a similar event occurring in future.”
Kim said the DHB acknowledged the coroner’s findings and was working towards implementing the recommendations.
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.
