Karl Pearce speaks last year at the opening on an art exhibition that included a work featuring his son, Braden. Photo: RNZ / Jimmy Ellingham
Warning - This story discusses details of suicide.
The father of a 19-year-old patient who died in a suspected suicide at Palmerston North Hospital's mental health ward is worried that a replacement facility will not open for more than two years.
Karl Pearce's son Braden died on 30 October, 2021.
A draft report from Te Whatu Ora, released to Pearce late last year, has identified failures in Braden's care and makes 24 recommendations following his death.
The hospital's mental health ward was ruled not fit for purpose after the deaths of two patients in 2014, and a new ward will be built.
The present ward is dingy and poorly designed, making it hard for staff to monitor patients.
But health officials have confirmed to RNZ the new building's construction is not expected to be complete until mid-2025.
This worries Pearce.
He said the ward should be a place where people can go to feel safe. Instead, since 2014, several patients have died.
Inquests into the deaths that year of Shaun Gray, 30, and Erica Hume, 21, were only held last year after long delays when the files were transferred between coroners.
Pearce attended and was unhappy to find failures from almost a decade ago, such as with communication between staff, were still a problem in 2021.
Now, Pearce is steeling for Braden's inquest, although a date has not yet been finalised.
"When the inquest does happen, hopefully it will answer more questions, but ultimately we want the inquest to serve the public and make sure that these deaths don't happen again."
Te Whatu Ora MidCentral mental health and addictions operations executive Scott Ambridge said officials were reviewing recommendations from a serious adverse events report and had prioritised "a number" of them.
"Of the 24 recommendations, eight are in progress and an additional four have already been completed.
"Actions that have been completed include changes made to our observation policy to better support tangata whaiora [patients] who are presenting with increased risk, improving the level of family-whānau involvement in care planning, and ensuring staff wellbeing."
Pearce was surprised to find there were no CCTV cameras on the ward's male wing, where Braden was staying, saying this would help with reviewing the incident.
Ambridge said: "Work has been done relating to the CCTV monitoring of the male wing and changes to reduce any potential environmental risks in the rooms, and these are progressing."
Policies not followed; information not passed on
Braden - RNZ is not using his last name at the request of Pearce - was found unresponsive about 6am on 30 October, 2021, eight days after his admission to the ward.
It was his second admission that month.
A draft of the serious adverse events report, seen by RNZ, outlines his stay and includes information Pearce was not previously aware of.
He was unhappy to learn his son's observations were downgraded when he was saying he had thoughts of suicide, and that Braden had what could be described as a practice run at self-harm the night before his death, but no information was passed to nightshift staff the day he died.
The report authors found after Braden arrived at the ward, a nursing admission assessment was done, but there was no care plan for his first 24 hours on the ward.
"The first 24-hour care plan was intended to inform the subsequent care plan, although in Braden's case there were no further care plans documented," the report said.
Initially, Braden was under observation every 15 minutes, as is policy for a patient's first 24 hours on the ward.
However, this policy was not followed and Braden's observation period was changed to once every 30 minutes inside that time, "without documented rationale".
Over the next few days, Braden was anxious and had suicidal thoughts.
After an incident observation was increased to once every 15 minutes, but a few hours later returned to once every 30, although there was no documentation for this change.
On 29 October, 2021, Braden reported to staff about the practice run incident. It is not clear when it happened. Observations remained at once every 30 minutes and there was no evidence his risk was re-evaluated.
That afternoon Braden had a meeting with two doctors and his grandmother. The practice run was discussed, as was the possibility of a return to the community.
Braden was not keen on one option - that he go to a facility in Feilding - because he did not feel that was safe for him, and was not told of other respite schemes. He said he felt like nothing was working to help him and nothing would work.
These thoughts were not passed on to staff working later.
The report found a lack of communication between staff, and that polices were not always followed - such as the one requiring staff to review observations and document this in patient notes.
The lack of communication or developing care plans meant some staff might have been unaware of Braden's particular vulnerability during evenings and nights.
There were requests for input from a psychologist, but this did not happen, and a "multidisciplinary meeting" involving staff such as nurses and key workers was cancelled because it fell on a public holiday and the ward was busy.
The report said these meetings were important to set a patient's direction and plan for their discharge.
It was not the only aspect of Braden's care that did not happen.
"Nursing staff are not doing subsequent care plans after the first 24-hour care plan. The nursing leadership acknowledge this does not meet the standards expected and leads to disjointed care," the report said.
The report also looked at the ward's staff. Some said the lack of a charge nurse for months meant there were gaps in the services provided.
"It was a common theme from the interviews that staff felt overwhelmed, busy, and tired for quite some time, with one nurse saying she felt 'burnt out' already after having only been on the ward for a short time."
Braden, in an artwork by Hana Tawhai. Braden died in a suspected suicide in October 2021. Photo: RNZ / Jimmy Ellingham
A father's concern
Pearce said he was surprised to find the practice run Braden talked about on 29 October, 2021, seemingly did not alter how he was treated.
"I would have assumed that would have an effect on how people dealt with him, but also that that would have been written down somewhere in the notes, but it doesn't seem to have been passed on from the day staff to the night staff."
Pearce saw similarities between how Braden and Erica Hume were dealt with. They were quiet, got on well with people and did not cause trouble, so could be overlooked.
Coroner Matthew Bates is yet to release his findings into Hume and Gray's 2014 deaths, but their inquest heard concerns about the ward, a view echoed by chief ombudsman Peter Boshier last year. In a report he said it was one of the worst in New Zealand.
Then-Prime Minister Jacinda Ardern visited in 2019 and said it did not look like the sort of place people would go to get well, and funding for a new $35 million ward was confirmed ahead of the 2020 election.
However, the opening date for the new ward has been pushed back at least two years from what was expected, leaving Pearce worried for patients in the meantime.
He also wants to make sure the new ward is fit for purpose when it opens and into the future.
"What is really disappointing is that some of the recommendations that are made in my son's report are also recommendations that have been made in past reports, coroner's reports.
"We, as a group of parents, really want to see other parents not having to go through the death of a child in an institution I suppose we believed was safe."
Ambridge said Te Whatu Ora extended its condolences to Braden's family.
He said he could not comment on some details about what happened to Braden because of the ongoing coronial inquiry and to respect the privacy some family members have requested.
Te Whatu Ora was well-aware the ward needed replacing.
Construction of the new ward would be led by LT McGuiness, and site clearance work was expected to finish later this month.
"Construction is scheduled to begin in February, and completion of the building is expected by mid-2025," Ambridge said.
"The new building will be welcoming, warm and make good use of natural light in order to enhance the therapeutic nature of spaces. The new model of care will enable us to offer support in a culturally appropriate environment, and offer flexibility for those in significant stress."
Officials were aiming to "transform the way the service is delivered" and were putting in time to make sure the new ward would be fit for purpose into the future.
Work on the safety and maintenance on the present ward was continuing, while the budget for staff had increased.
Pearce, meanwhile, has endured a tough time mourning his son, who he remembers as a vibrant young man who was into art, music and magic - he would learn tricks or new songs from YouTube.
"He was just a really neat person and I was really looking forward to watching him live his life."
In February last year a work featuring Braden, by Palmerston North artist Hana Tawhai, was included in an exhibition in the city, Waitangi, Why Tangi, Why we Tangi.
At the exhibition's opening on a hot Friday evening Pearce spoke about Braden.
He's doing so again now in the hope lessons learned from his death will prevent more.
"Whether it's a brand-spanking new building or whether it's more nurses on the ward.
"Sadly, it's just taken the deaths of some of our kids to get there."
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
Lifeline: 0800 543 354 or text HELP to 4357
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
What's Up: free counselling for 5 to 19 years old, online chat 11am-10.30pm 7days/week or free phone 0800 WHATSUP / 0800 9428 787 11am-11pm Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi and English.
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
OUTLine: 0800 688 5463 (6pm-9pm)
If it is an emergency and you feel like you or someone else is at risk, call 111.