Preventable death: Coroner finds Palmerston North Hospital failings linked to death of Erica Hume

WARNING: This story deals with suicide and may be distressing for some people

Twelve years after Erica Hume took her own life her parents are still asking why.

Answers to some of their questions have arrived in a 218-page coroner’s findings released today, and, while it doesn’t bring “closure”, it does set a benchmark for a new beginning, her mother, Carey Hume, told NZME.

“The findings are a reminder of what we lost and what Erica lost because people didn’t do their job.

“We loved Erica. She was a young, vibrant student with so much potential and all she needed was someone in Ward 21 to pay attention to her, and actually help her when she realised, no, her safe haven had turned into a horror story,” Carey said.

The “curious country girl” who grew up on a North Island kiwifruit orchard took her own life at age 21, after she was admitted to the mental health ward at Palmerston North Hospital.

The Humes have in recent years spoken publicly about what happened, not only in their search for answers but to ensure the narrative around their daughter was accurate.

“We knew our daughter,” Carey said.

“She was fully functional, studying, achieving great grades, well presented, had got herself a part-time job.

“She didn’t meet the picture of someone supposedly with mental health issues and that was half of the battle,” Carey said of the family’s pleas for help.

Death was ‘preventable’

Erica had been admitted to the ward on May 6, 2014.

The following day, a nurse’s hunch about her fragile state turned out to be true, but a decision to check on her was minutes too late.

Erica was found in her room in the ward alive but unconscious, after she was seen returning from lunch in the dining room.

Resuscitation efforts began immediately by staff and then continued once an emergency team arrived, but Erica remained unconscious.

She was moved to the intensive care unit but her condition deteriorated, and she died nine days later.

Coroner Matthew Bates was critical of hospital management and staff for a series of failures linked to what happened.

He said her death was preventable.

Health New Zealand said in a statement to NZME that it accepted the coroner’s findings and recommendations and was committed to ensuring it learned from what happened.

The national director of mental health and addiction services, Phil Grady, said HNZ extended its deepest condolences to Erica’s whānau.

“Erica’s death has had a profound and lasting impact on her loved ones, and we acknowledge that this pain continues,” he said.

Self-harm occurred day after admission

The self-inflicted harm which led to Erica’s death happened the day after she was admitted. She died in the early hours of the morning on May 16.

Carey said as macabre as it might sound, the delay was a “gift” because they had time to say their goodbyes, and time to start asking questions.

Erica’s death happened a month after the death of her friend, 30-year-old Shaun Gray, in the same ward, which had a big impact on their “sympathetic and empathetic” daughter, Carey said.

“As horrible as it was, and as traumatic for us and her siblings, we had those 10 days because if she had died straight away, we might never have found out information they [staff] were not telling us.”

The family didn’t know Erica’s phone had been misplaced on admission and she was unable to call them.

It was a point raised by the coroner. He said if Erica had had her mobile phone on May 6 and 7 she would have had a greater opportunity to reach out to her friends or parents for additional support.

A coronial inquest into Gray’s death raised multiple issues about the way the hospital handled his care, NZME reported in 2022.

Coroner Bates said the circumstances around Erica’s death highlighted gaps in resourcing and failures around adhering to adequate policy and procedures in place at the time, but they were not properly followed.

He said that had they been, it may have prevented Erica’s death, or at least materially reduced the chances of it occurring.

Coroner Bates said the circumstances around Erica’s death highlighted the limited nursing resources available to Ward 21 at the time, the absence of a cohesive team nursing approach, and a poorly designed ward that was “never fit for purpose”.

He acknowledged that a new acute mental health facility at the hospital, Ngā Wai Ngāro, was now operational but said any lessons learned should be applied to the new unit.

Grady, on behalf of HNZ, said mental health inpatient services were complex environments that provided care for people who were often highly unwell and in acute distress.

“We recognise there is always more work to do to ensure we provide safe, high-quality care for patients and a safe working environment for staff,” he said.

Coroner Bates found Erica intended to end her own life, but acknowledged her family’s view that, ultimately, in a more general sense, she did not want to die.

He also acknowledged that when she was admitted to Ward 21, she was actively seeking help from mental health services to try to live.

Classified as ‘high risk’

According to evidence heard at the 2022 inquest, in 2014 Erica called her care worker at Palmerston North Mental Health Services and said she was having thoughts about harming herself.

The next day, she was admitted to Ward 21 on a voluntary basis. Her care worker filled out a risk assessment form, classifying her as “high risk”.

However, staff at the ward left her admission paperwork for the night shift to complete and no formal assessment of her risk was undertaken while she was in the ward’s care.

Overnight, she was checked every half hour. The next day, she briefly left her room for lunch before returning.

It was just before 1pm when she was found unconscious in her room.

Mental health journey began years earlier

Owen Hume told the inquest his daughter’s mental health journey started years earlier when she was in Year 12 and told a teacher she “wasn’t doing too good”.

She was referred to the school counsellor who took Erica to a doctor who prescribed anti-psychotic medication. Meanwhile, she developed multiple eating disorders.

All of this occurred without her parents’ knowledge.

“I knew something wasn’t right but as a mum of a teenage girl, you try to figure things out and not upset them. You nurture them through but it was the beginning of the end in that respect,” Carey said.

By the time they found out and the Bay of Plenty District Health Board became involved, it was too late for her to access youth mental health services.

The Humes tried to get mental health support while Erica was attending Massey University in Palmerston North but she was deemed “not bad enough”.

It was recommended that she access the university’s counselling services.

Massey quickly established that Erica’s situation was too serious for them to deal with and referred her back to Palmerston North Mental Health Services.

Contributing factors

Coroner Bates found several contributing factors linked to Erica’s death, including her mental state at the time, plus failure by Ward 21 staff to complete a risk assessment form upon Erica’s admission.

Ward staff also failed to carry out observations in accordance with MidCentral District Health Board (MCDHB) policy and procedure.

The actions which led to her death “demonstrated a degree of premeditation and planning to end her life”, Coroner Bates said in the findings.

“Her intent crystallised after she learned that Mr Gray had ended his life.”

“No one checked on Erica for a critical 55-minute period on the morning of May 7, 2014, during which the nurse allocated to Erica’s care was absent from the open side of Ward 21.”

Coroner Bates said if a psychiatric assessment had taken place following her admission to the ward, it may have alerted nursing staff to her heightened risk of suicide by the method she chose.

However, Coroner Bates accepted it was not always possible for assessment to occur immediately after admission, particularly if it was later in the day or during the evening after the ward psychiatrists had left.

Ward operating ‘at or over capacity’

The consultant psychiatrist on Ward 21 intended to assess Erica as soon as possible the day after she was admitted but couldn’t because of high demands on the ward that morning, and the need to prioritise other “overtly” acutely unwell patients, the coroner said.

“This highlights the fact that Ward 21 was often operating at or over capacity, with high acuity, and with limited staffing resources,” he said.

Recommendations made by the coroner included that admission documents should be completed at the point of admission and that psychiatric assessment of newly admitted patients should occur as soon as possible.

There was also a need for clearer protocols for staff to easily identify observation levels in place for each patient, plus the introduction of training audit systems to monitor whether staff were meeting training requirements.

Health New Zealand MidCentral said significant progress had already been made in implementing many of the recommendations.

Grady said in the 12 years since Erica’s death, significant changes had been made across mental health services, including the move to the new purpose-built acute mental health unit, which opened in February.

“Our model of care has also evolved. Since Erica’s death, we have seen the introduction of a shared electronic patient record across community and inpatient services.

“This has strengthened clinical handovers and improved visibility of patient information, supporting more timely and informed decision-making,” Grady said.

Relief for family

Coroner Bates hoped the conclusion of the inquiry would bring some relief to all those affected by Erica’s death, in particular her family.

Carey said it was less a closure than a beginning.

“For us, it’s about the hospital management and staff having to start having accountability now.

“I say that because our experience over the past 12 years is that no changes last. You’re lucky if they last 12 months before they’re either ignored or dropped altogether.

“But you’ve got to hope there’s change and reports aren’t put in the bottom drawer and forgotten about.”

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.