A nurse responsible for the care of a Palmerston North mental health ward patient who died in a suspected suicide did not check on him for an hour before he was found unresponsive.
Shaun Gray who died on 16 April 2014. Photo: Supplied
Shaun Gray died on 16 April 2014, having been admitted to the ward's high-needs unit earlier that afternoon. He was supposed to be watched closely.
An inquest into his death in Palmerston North on Tuesday heard from the nurse charged with overseeing the 30-year-old's care that afternoon and evening.
The nurse, who has name suppression, is not appearing as a witness, but her statements and answers to questions from lawyers were read.
The decision to excuse the nurse's appearance was behind the Gray family's decision not to play an active role in the inquest, although family members are watching from the public gallery.
Gray was admitted to the unit after he was rushed to the hospital's emergency department following an overdose the previous day. He admitted having suicidal thoughts.
The nurse, who at that stage was inexperienced, said his behaviour was aggressive throughout the afternoon of 16 April, and this was made worse by problems with his prescription medication.
Gray refused to take his night medication and had a heated phone call with his father.
Nearing the end of a "hectic" shift the nurse observed him asleep on the mattress on the floor of his room at 10pm.
After seeing his aggression during his phone call the nurse said she was too terrified to closely look at him.
Minutes later the nurse asked colleagues if she could leave the high-needs unit to complete notes for the shift. They said that was OK, repeating this when she returned to the unit to check, she said.
Answering questions from lawyers representing other workers on the ward, the nurse said she understood that when she or others left to write notes other staff would watch their patients.
Asked if it was her responsibility to arrange care for her patients, the nurse agreed, saying she thought the colleague she spoke to about leaving would do this.
"I did not think at any point while I was out of the room that checks had not taken place."
Gray was found unresponsive in his room about 11pm, having not been checked on since 10pm.
"I expected other nurses to check on him when I was not in the [high-needs unit]," the nurse said.
"I feel it's important to note the following: Very senior staff were very aware that I was struggling with Mr Gray the entire shift and, as they had so much experience, I expected them to support me, a relatively new nurse in the acute mental health area.
"Mr Gray was my first very aggressive patient and I had been told I was doing well by [another nurse with name suppression] during my shift."
The nurse said although she knew of Gray's earlier suicidal thoughts, a handover from a nurse on an earlier shift led her to believe his risk had reduced.
In the afternoon, Gray was "irritable and angry already".
In the unit, the nurse said three staff members would oversee six patients.
Gray faced further frustration when a doctor decided his prescribed 0.625mg daily dose of triazolam should instead be 0.0625mg. Later this was adjusted to 0.25mg, but staff could not initially find the drug on the ward.
Coroner Matthew Bates who is overseeing the inquest. Photo: RNZ / Jimmy Ellingham
Methadone dose for patient 'out of step' with NZ practice
Gray was at one stage prescribed methadone doses more than three times the recommended upper limit.
A doctor, whose name is suppressed, said that Gray in early 2013 was taking 390 milligrams of methadone a day as well as other prescribed drugs.
Methadone is used to help addiction patients break free of their reliance on other drugs, and 120mg a day is considered at the upper limit of what should be prescribed.
The high dose was prescribed by Dr Sarz Maxwell, who left the MidCentral District Health Board in mid-2013 and returned to the United States.
"The doses were higher than those usually prescribed in New Zealand," said the doctor giving evidence.
"She had published journal articles to support her view, but it was out of step with New Zealand guidelines."
Increased medical risks were among possible side effects of high consumption of methadone, he said.
The inquest heard on Monday that Maxwell's prescribing practices were of concern to senior MidCentral officials, and they were among the 43 issues Coroner Matthew Bates wanted discussed at the two-week inquest.
The doctor said such high doses for clients were gradually lowered and Gray, who had an opioid addiction, mostly coped with this, including during periods under supervision.
By early 2014 he was taking 100mg of methadone a day, but the doctor raised this to 120mg, and changed another drug Gray was prescribed.
Gray was moved off midazolam to triazolam to help with sleeping difficulties.
The doctor said he was not comfortable with midazolam being prescribed daily, saying it was more commonly used in the leadup to medical procedures.
This move was another the coroner wanted examined.
"I have no reason to believe that the change from midazolam to triazolam contributed to any change in Shaun's mood," the doctor said.
On 15 April 2014 Gray went to MidCentral's alcohol and other drug service upset a chemist would not give him a takeaway dose of methadone.
The doctor said he could not find any mention of past suicide attempts in Gray's medical notes.
When the doctor last saw him before 15 April, in late March, he wrote Gray was "going well".
They discussed the possibility of allowing Gray to take away doses of methadone so he would not have to go to the chemist every day, but other staff later decided he wasn't ready.
Gray's behaviour on 15 and 16 April, including attempts to bite and scratch medical staff, was out of character.
The doctor said he had never seen such a reaction to being declined takeaway methadone and presumed something else was troubling Gray.
Gray remembered as 'friendly guy'
Pharmacist Glen Caves dispensed Gray's prescription drugs in early 2014, including methadone.
"My recollection of Shaun was that he was quite a friendly guy. I do not recall seeing him angry."
Pharmacist Glen Caves gives evidence at the inquest. Photo: RNZ / Jimmy Ellingham
Caves, who has since retired, said Gray knew his prescription entitlements.
Gray was on a mixture of medications for anxiety and sleep problems.
His daily triazolam dose of 0.625mg was above the recommended limit of 0.25mg, but addicts could often develop high levels of tolerance, Caves said.
On 15 April Caves declined to give Gray takeaway methadone because there had not been an instruction from MidCentral addiction staff.
He could not recall the specifics of the situation, but said Gray was frustrated, rather than angry.
The mental health ward, which has been found not fit for purpose, is being replaced.
The inquest continues.
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