Samara Jade Visser died after absconding while on a walk with a nurse outside an Auckland mental health unit. A coroner has now released findings on the case. Photo / Facebook
Samara Jade Visser died after absconding while on a walk with a nurse outside an Auckland mental health unit. A coroner has now released findings on the case. Photo / Facebook
Warning: This article discusses suicide, self-harm, and other mental health problems. If you need help, contact Lifeline on 0800 543 354 or text 4357 (HELP).
A coroner says the death of a mental health in-patient would probably not have occurred if Auckland District Health Board had responded more urgently to her going missing on a walk with a nurse.
Samara Jade Visser’s body was found in Point Chevalier on June 2, 2019.
She had been an in-patient at Te Whetu Tawera, a mental health ward at Auckland City Hospital, and managed to abscond while on a walk with a nurse three days earlier.
Due to hospital staff categorising her incorrectly, an active police search for Visser was delayed by 18 hours.
Coroner Tania Tetitaha’s findings, released to the Herald, ruled that Visser’s death was a suicide and there were “failures in the immediacy of the response by the ADHB (now Te Whatu Ora Te Toka Tumai Auckland) which led to her “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.”
Te Whatu Ora Te Toka Tumai Auckland has acknowledged the Coroner’s findings and said the mental health team had “fully implemented all the recommendations” in the decision.
Visser had a long history of mental illness and had been diagnosed with bipolar disorder and ADHD. She spent time in the Mason Clinic in 2016 as a special patient detained after she was convicted on criminal charges.
In 2018 she was admitted to Te Whetu Tawera after she started having “manic thought disorder and delusions” and was found “fighting off demons in the kitchen’” of her home. She was discharged but readmitted after she became increasingly delusional - insisting she had “received instructions from God to self-harm”.
Samara Jade Visser died in 2019 after she took off from a nurse on a walk outside the mental health unit she was ordered to stay at. Photo / Facebook
Over the next five months Visser’s mental health “continually fluctuated” and she moved between the TWT’s intensive care unit and the ward.
She was a ward patient when she died, even though she continued to report “auditory hallucinations about God” and was still regarded as being at risk of self-harm.
Despite this, Visser was granted supervised leave from the hospital.
On May 31 she was on such leave when she absconded.
“(That day) she was assessed by a doctor when she continued reporting ‘bad thoughts’ in her head but it was believed she had no thoughts or intentions to harm herself,” Coroner Tetitaha said.
“However, Ms Visser was planning to abscond.”
She had asked her ex-partner to deposit money into her account and messaged a friend that she had “decided to AWOL (absent without leave)” and wanted to come and stay with her.
At 3.30pm Visser’s ward nurse agreed to take her for a walk.
They went to an ATM and a nearby shop so Visser could purchase a Fanta, then, as they walked back to the ward, Visser “suddenly ran”.
The nurse gave chase but Visser said: “just let me go. The doctors don’t listen to me … I just want to go and live and be free.”
Visser ran around a corner and the nurse lost sight of her and walked back to the hospital to start the AWOL process which involved filling in the patient details and contacting the duty manager, on-call doctor and urgent response team.
“Ms Visser was categorised as AWOL Cat B, which meant that if she had not returned by the next morning it would be changed to AWOL Cat A, which it was assumed would involve the police and the urgent response service would start actively looking for her,’ said Coroner Tetitaha.
Visser made it to her friend’s house but left early the next morning.
At the same time hospital staff re-categorised Visser as AWOL Cat A and the police ramped up their involvement.
At about 7.20am on June 2, Visser’s body was found by a member of the public in Point Chevalier.
Following Visser’s death, the ADHB Adult Mental Health Services undertook a serious adverse event review and provided a report to the Coroner.
A Coroner has ruled the ADHB could have acted quicker when Samara took off and her death "would not have occurred". Photo / Facebook
“The review identified several care delivery issues that contributed to this event,” said Coroner Tetitaha.
She said the issues included:
The incorrect AWOL category which delayed the police search
The fact the AWOL policy was not operationalised in adult mental health.
Not discussing which category to place Visser in with senior medical staff or the Medical Director of Area Mental Health Services - if it had it was likely she would have been upgraded
Coroner Tetitaha said the review found that ADHB staff did not use the AWOL policy consistently and there was confusion and that Visser being placed in the incorrect category led to “an 18-hour delay in police commencing an active search”.
“Ms Visser should have been categorised Cat A AWOL because she was a ‘high and enduring’ risk alert. However, this was not identified by staff nor communicated to the police,” the Coroner said.
“The review found that there was a lack of clarity amongst staff about the police search plan and actions. This led staff to think that more active searching for Ms Visser was occurring than was actually the case.”
A number of recommendations were made by the review team, including the ADHB implementing an AWOL process that “explicitly outlines responsibilities for police and mental health services”, and clarifying it with all staff and revising the AWOL form in collaboration with police.
“There were risk factors for suicide in the circumstances leading to this death,” the Coroner said. “Ms Visser had an extensive mental health history, including a diagnosis of bipolar disorder.”
The Coroner added it is “likely Ms Visser’s bipolar disorder contributed to her mood and decision-making leading to this death.”
“The ADHB should have fully implemented the recommendations set out in the External Serious Adverse Event Review report dated 16 December 2019.
“There is also a need to train staff regarding the AWOL policy.”
Samara - described as "a beautiful soul" - is survived by her son. Photo / Facebook
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.”
He said the organisation has “worked alongside Ms Visser’s whānau” throughout the external review process, and met with them to offer our apologies and condolences.
Shepherd acknowledged the Coroner’s findings and said the mental health team had “fully implemented all the recommendations”.
“The implemented recommendations to improve our systems and processes are now well established and help our kaimahi provide high-quality care to our service users.
“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.”
