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The family of the man who took his own life after walking out of a mental health unit are seeking an apology after a coroner's report found deficiencies in his care.
Nicholas Taiaroa Stevens, 21, who was known as Nicky, walked out of the Waikato DHB's mental health unit on 9 March, 2015.
His body was found in the Waikato River three days later.
He was a patient in the District Health Board's mental health unit - the Henry Rongomau Bennett Centre (HRBC).
Coroner Wallace Bain ruled the death as a preventable suicide.
He found the treatment Mr Stevens received from the DHB fell well short of what he and his parents would have expected.
"As a result of the deficiencies in his care, he was able to take his own life in the precise manner and place that he had previously said he would."
Mr Bain said the circumstances surrounding Mr Stevens' death made it quite clear that the mental health system was in urgent need of being overhauled and significant changes implemented.
The court also looked at the police response to Mr Stevens' death, after it was noticed he was missing at about 1pm.
"Ms Stevens was notified at 2pm. She was called by Nurse A, and asked about locations that Mr Stevens might have gone to. She alerted Nurse A that he might well be down at the river because he had indicated that that would be.
"A missing person's report was sent by fax from Nurse A to police but police did not pick it up until 1 o'clock the following morning and the fax had gone through partially cut off meaning the box indicating that Mr Stevens was at risk of suicide was not easily visible.
"Family were not contacted by Police; rather [Jane] Stevens visited the Hamilton Police station herself to see what was being done. She received an incident number, and mentioned that she had been told by the HRBC that Police were searching the area, including down by the river.
"No such search was occurring."
The Independent Police Conduct Authority (IPCA) has investigated the police's response.
"It is well acknowledged that the police response could have been better. The improvements Police have already made should be commended," Mr Bain said.
The family also submitted to the court that they did not believe they were included adequately in Mr Stevens' treatment.
Waikato DHB interim chief executive Derek Wright said it received the coroner's report yesterday.
"The death of Nicky was a terrible tragedy and this has been a long and painful journey for everyone involved, both the family, our staff and the wider community. I want to express my sincere sympathy to Nicky's family for their loss.
"We will now be working through the findings and recommendations in the report."
"With the release this week of the mental health inquiry report we look forward to the continuing importance and focus placed on mental health services in New Zealand."
Nicky's parents are seeking an unqualified apology from the DHB
Jane Stevens, Nicky's mother, told Morning Report it was a bittersweet moment for them and it was good to see the coroner's report vindicated all the action they took as well as concerns raised to the DHB.
She said putting the report into the nationwide mental health inquiry would allow them to at least "honour [our] son by seeing some of the changes we've called for happen".
Ms Stevens said her son's death was a poignant example of why an overhaul of the mental health system was needed.
Dave Macpherson, Nicky's father, told Morning Report given that this has come a few days after the mental health inquiry's report, it gave them hope for change.
"[It] gives some hope that it will be seen in a broader context and they can't just fix a couple of problems at the Waikato DHB - it's nationwide, it's an issue."
He said there have been some changes implemented at the DHB as a result of the case but said it wasn't enough.
"They have a few more security guards on and a few more locks on the doors, but the culture, in my opinion, hasn't changed up there yet and we're sort of a bit disturbed to think it's taken all this time to do some minor changes.
"I think there's a resistance to culture change there and it needs a culture change, I mean as a family we were not listened to, the so-called mental health professions thought they knew best, they ignored our warnings, very explicit in writing.
"If they had heeded our warnings and taken some basic steps, our son may very well have been alive."
Ms Stevens said they'd been contacted by many families in similar situations and encouraged those parents to keep fighting.
"We found you just have to be a squeaky wheel and that's really hard when your family member is vulnerable, and we kept on speaking out ... and the terrible thing is even that wasn't enough, but I think that more people are listening now," she said.
"It's really important that parents act early and don't give up, just keep going, and get support."
Mr Macpherson agreed that parents should be firm in their approach to authorities if they were in a similar situation.
"We thought we were fighting hard, but we didn't fight hard enough."
Nicky's parents will also seek a meeting with the Health Minister to go over the report and will be requesting an apology from the government.