VJ Sheldon Tutai was found dead at a school playground in Hamilton in 2018. Photo / 123RF
VJ Sheldon Tutai was found dead at a school playground in Hamilton in 2018. Photo / 123RF
A coroner has ruled the death of a man - whose body was found at a school playground - was self-inflicted, and that the 23-year-old had likely been suffering from low mood due to drug withdrawal.
However, Coroner Matthew Bates has made several recommendations for the care home that VJ Sheldon Tutai had been living in at the time including “revisiting” its policy of waiting 24 hours before reporting a resident’s absence.
Tutai was under a compulsory treatment order after being released from the Henry Rongomau Bennett Centre at Waikato Hospital in 2017 and placed in the Connect care home Waatea - now called Ember - in Hillcrest, Hamilton.
A year later, he was considered in a good space with no cause for his whānau or workers at the home to suspect he may be at risk of harming himself.
However, on the morning of September 8, 2018, his body was found by members of the public.
Tutai, who had paranoid schizophrenia and was addicted to cannabis and cannabinoids, known as synthetic cannabis, was under the influence of drugs for 124 days during his time at the care home.
Whānau, and the general manager from Ember, believed there was something, or someone, more sinister involved in his death as he had told them he owed money to people for a drug debt, which sparked the coroner’s inquest.
However, in his findings, publicly released today, Coroner Bates said there was “no compelling evidence to suggest another person was involved” in Tutai’s death.
He said Tutai was thought to have been withdrawing from synthetic drugs for about two weeks, and although an autopsy found cannabis in his system, it was unclear when that was ingested.
The coroner also found the death could not have been prevented.
“There were no obvious signs to any person involved in Mr Tutai’s care, or to whānau, that he was about to take steps to end his life.”
The coroner was asked to look at the circumstances of Tutai’s death, the care provided by Ember and its policies, and actions by police and Te Whatu Ora Waikato.
Tutai had lived with whānau in Tokoroa before becoming unwell.
His sister said he was popular at school, was qualified in personal training, loved music, cooking, fitness, and was known as a “clean freak”.
His mental health began declining when he was 16, and in 2011 he began hearing voices but would listen to music to try to block them out.
VJ Sheldon Tutai was released from the Henry Rongomai Bennett Centre, pictured, a year before his death. Photo / Michael Craig
He was admitted to Henry Bennett in 2017 and after his health improved he was transferred to Ember on a compulsory treatment order.
Despite the challenges he faced, he was loved by not only his whānau but those involved in his treatment.
At Ember, residents’ movements were not restricted and what they did daily was up to them.
“Drug use amongst residents was prominent,” the coroner said in his findings.
“Drugs and alcohol were not allowed on site, but there was no ability to prevent residents from consuming them off-site.“
However, Tutai’s mother believed her son would be supervised by Ember day and night which gave her and her husband “a sense that he would be safe and protected”.
But Ember “was not, and was never intended or purported to be a secure or supervised facility”, the coroner said.
Mental health clinicians felt when discharging him from Henry Bennett that Ember was appropriate for Tutai as the ward he had previously been in was “a fairly relaxed and open environment”.
The day before his death, Tutai “bounded” into a staff member’s office saying he’d been doing well while “off the drugs”, and was feeling “really good”.
She described him leaving her office “with a spring in his step” and in a more positive mindset than days earlier when he’d heard “the voices” which were “louder and annoying”.
She felt there was nothing to suggest he was in danger of harming himself.
Just after midnight, he was checked on by a different staff member and appeared to be sleepy as the pair said goodnight to each other.
When checked on again at 3am, Tutai’s door was locked so the worker looked through a gap in the curtains and saw a lump in the bed and presumed it was him sleeping.
At 6am, he unlocked the door and went inside to realise Tutai wasn’t there.
CCTV footage from a school showed a person wearing a white shirt or jacket walking past at 2.32am who the coroner deemed was Tutai.
Tutai, whose music was still playing through his headphones, was found just after 7am.
Among Coroner Bates’ recommendations, he advised Ember to reassess its security and harassment policies, and conditions upon use of internet-capable devices.
In response, Ember confirmed residents' use of laptops was now more “considerably controlled” and the Waatea service was no longer in operation.
The care home had also addressed the other recommendations including that a report should be made to police within 30 minutes of a resident not returning on time.
Belinda Feek is an Open Justice reporter based in Waikato. She has worked at NZME for 10 years and has been a journalist for 21.
