Coroner never saw hospital investigation before ruling on death

Warning: This story mentions suicide

• Coroner rules Philip Lucas' cause of death undetermined
• He took leave from Palmerston North Hospital's mental health ward and never returned
• A hospital investigation found shortcomings in his care
• The coroner hasn't seen the investigation report

The family of a man found dead after he failed to return to the Palmerston North Hospital mental health ward is unhappy a coroner did not see the report from a hospital-led probe, which found shortcomings in his care, before ruling on the death.

Philip Lucas was granted leave from the ward on 24 December 2022. The 69-year-old's body was found just over a month later in the Kāpiti area and a coroner's report - released on Monday - has found the cause of his death could not be determined.

Coroner Peter Ryan said the threshold to rule it was a suicide was not met, and a pathologist found it was also possible Lucas died from "natural causes related to his smoking-related lung injury".

In his three-page decision, the coroner said Lucas was assessed by two mental health professionals before he was granted leave, and they found his risk of self-harm was moderate.

"It appears the decision to grant Mr Lucas leave was reasonable."

However, a serious adverse event review into Lucas' death, which the coroner did not see, outlined problems with the recording of key information concerning Lucas' stay and a lack of clarity about communication with his family.

The report made eight recommendations, including about improving communication with families, better recording of information to the clinical record, and strengthening leave procedures.

A spokesperson for Lucas' family said Coroner Ryan should have seen the hospital report.

"The findings of that are quite pertinent to the context of him [Lucas] going missing," they said.

"I think our family really deserves a few more answers that what we got."

Health NZ group director of operations for MidCentral Sarah Fenwick said: "Serious adverse event reports are provided to the coroner's office, upon request.

"The coroner's office did not request a copy of this report."

It appears, however, the coroner did not realise there was a report.

An email, seen by RNZ, from the coroner's case manager confirmed as such: "I am not aware that a serious adverse event review has been completed by Health NZ-Te Whatu Ora."

The case manager said such reports looked at "the standard of care for a patient and identifies any failing or opportunity for improvement".

"Again, this is only relevant to a coronial inquiry if the death occurred as a direct result of a failing in the standard of care provided."

The Lucas family spokesperson said they were shocked Coroner Ryan had not seen the report, and asked how a coroner would know if such a report was not relevant if they had not read it.

They also said they mentioned the serious adverse event process in an email with the coroner's case manager in June 2023.

"I really thought he [the coroner] would have received that report a long time ago. I think we were sent the final copy in June or July [last year]."

The spokesperson said the hospital report outlined the context of how Lucas went missing.

Given the issues raised the spokesperson said they would have liked an inquest, which provided the opportunity to ask questions, find answers and, ultimately, get closure on a traumatic event.

Instead, they felt important issues, including with the search for Lucas, were not looked at.

"I feel they've been very quick to shut the book on this," the spokesperson said.

"I'm gutted for Philip, because it doesn't really do him any fairness."

The family spokesperson said they had now contacted the coroner's office about the hospital report's existence in the hope the inquiry into Lucas' death could be reopened.

Coroners do not comment on their findings. RNZ has requested comment from the coroner's office.

Health Quality and Safety Commission guidelines say a "SAC 1" death, which would result in a hospital investigation and report, include: "Suspected suicide by any consumer receiving care, treatment and services in an inpatient or monitored community mental health and addiction residential setting (eg, respite) or within 72 hours of discharge (includes approved and unapproved leave status)."

Lucas' death would fall into this category.

He was admitted as a voluntary patient at the Palmerston North Hospital mental health ward about two weeks before he didn't return from leave, although his family wanted him held as a compulsory patient.

Before his admission, Lucas made an attempt at suicide, but his family were unaware of this when planning for his discharge.

The hospital report found shortcomings with the hospital's communication to Lucas' family and between staff at the mental health ward.

When he was granted leave, Lucas spoke of visiting his daughter, although his daughter had previously told another staff member she didn't want him visiting her at home.

Also, Lucas had previously mentioned a desire to drink alcohol in the community, something not passed on to the registered nurse who granted him leave on 24 December.

The hospital report found this registered nurse had no way of knowing it was unlikely Lucas would be visiting his daughter, and the lack of recording his plans about visiting a pub "limited the insight of the clinical team into the level of risk unescorted leave may pose to Philip's wellbeing".

The coroner said Lucas denied having suicidal ideation on 23 December, 2022, after two weeks of improvement.

Lucas was reported missing on Christmas Eve.

A search of the hospital grounds and security footage happened on 29 December.

In 2017, Simon Oakley, a voluntary patient at the ward, died by suicide after taking leave. Despite being just metres from the ward's entrance, his body was not found for six days.

After Oakley's death, for which a coroner's inquest was held, the then-MidCentral District Health Board head of security said from then on security workers would immediately obtain more information about missing patients and call in extra staff if patients had not returned within 72 hours of taking leave.

It was also unclear when Lucas' phone was found in his room on the ward, which his family believe could have affected where the search for him focused.

On the hospital report, Fenwick said: "Health NZ MidCentral has accepted the serious adverse event report's eight recommendations and has work underway to address each of them. We are committed to ensuring improvements arising from these recommendations will endure and be effective."

The Palmerston North Hospital mental health ward was found unfit for purpose in 2015, after the deaths the year before of patients Shaun Gray, by suicide, and Erica Hume, in a suspected suicide.

A new ward will open in the middle of this year.

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. 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 or text 4202
• Samaritans: 0800 726 666
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz
• What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds
• Asian Family Services: 0800 862 342 or text 832. 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
• Aoake te Rā bereaved by suicide service: or call 0800 000 053

If it is an emergency and you feel like you or someone else is at risk, call 111.