Uni student’s death at Palmerston North mental health ward was preventable, coroner rules

Warning: This story discusses suicide

• Death of 21-year-old university student at Palmerston North Hospital mental health ward in 2014 ruled a suicide
• Coroner Matthew Bates says Erica Hume’s death could have been avoided if staff followed policies and procedures
• Erica Hume’s parents hope coroner’s report will result in change
• Health NZ says it will implement all of the coroner’s recommendations

The death by suicide of a 21-year-old university student in an overcrowded mental health unit that wasn’t fit for purpose was preventable, a coroner has found.

Coroner Matthew Bates said Erica Hume’s death in May 2014 at Palmerston North Hospital could have been avoided if staff at the unit had correctly followed policies and procedures.

Hume’s parents Carey and Owen Hume say they hope Coroner Bates’ ruling, which runs to more than 200 pages, will result in change and prevent further deaths.

Health NZ says it accepts the coroner’s findings and is working to implement the 20 recommendations detailed in the report.

Hume died just a month after Shaun Gray died by suicide in the same hospital ward - a death Coroner Bates also found preventable, in a ruling released last year.

The coroner said staff at the old unit, known as ‘ward 21’, were under pressure due to limited resourcing and overcrowding, and lacked a cohesive team approach.

The old unit itself was “a poorly designed unit that was never fit for purpose,” the coroner said.

“I consider the policies and procedures in place for ward 21 at the time of Erica’s death were adequate, and that adherence to them may have prevented Erica’s death or at least reduced the changes of it occurring.

“I find that management and staff failures to ensure those policies were adhered to resulted in Erica receiving suboptimal care, which ultimately enabled her to take her own life.

“Her death was avoidable.”

Hume and Gray’s deaths prompted reviews of the ward, which found it unfit for purpose.

Funding for a new ward was confirmed before the 2020 election and after delays it opened last year. Patients moved in from early February.

Meanwhile, the coronial cases faced years of delay - for which the Hume and Gray families have received apologies - before the files were assigned to Coroner Bates and inquests held in 2022.

There were other deaths of ward patients, including a teenager in 2021, where an internal report identified issues such as a lack of communication between staff.

Shaken by friend’s death

Hume was admitted to the ward on 6 May 2014, after seeing the community mental health team.

The Massey University student had previously been a patient on the ward, and saw it as a safe space.

However, that view was shaken when she learned that Gray, a friend of hers, had died there.

Coroner Bates found four factors contributed to Hume’s death, including her mental state at the time and stressors in her life, such as Gray’s death.

One factor cannot be reported, due to restrictions on publicising the method of a death by suicide, but another two relate to hospital staff not following policies and procedures.

No risk-assessment form was completed when Hume was admitted to the ward, and staff failed to complete her admission documentation in a timely manner.

That meant her “heightened risk of suicide” and other vital information were not documented, so staff appeared unaware she needed close monitoring.

Staff also failed to carry out observations of Hume in line with policies and procedures. No copy of the standard form recording this information about her can be found.

“Accordingly, there is no record of observation intervals nor any pertinent information arising from an observation completed,” Coroner Bates said.

Hume’s observation level was set at once every 30 minutes, but it should have been once every 15 minutes if she was suicidal, particularly once it was known she’d found out where Gray had died.

On 7 May 2014, shortly before the incident that ultimately resulted in her death nine days later, there was a long gap when she was left alone.

Crucially, she was without her mobile phone, which she had mistakenly left with community mental health services, meaning she couldn’t contact friends and family without making a toll call. The coroner said this could have added to her sense of isolation.

Hume’s room was down the end of a corridor in the section of the ward known as ‘the openside’.

“No one checked on Erica for a critical 55-minute period on the morning of 7 May 2014, during which the nurse allocated to Erica’s care [Juliet Kereama] was absent from the openside of ward 21,” the coroner said.

“Whether Erica should have been on constant observations, 15-minute observations, or the standard 30-minute observations, there was a failure to observe hospital observation policy.”

When Kereama was absent - to cover on the ward’s high-needs unit and then attend a short medical appointment - nobody was assigned to check on Hume.

Hume was seen after this period, and then was soon found by Kereama, injured.

Among the coroner’s recommendations are that admission documentation should be completed on admission for patients, or at least within the same shift.

He recommended better record-keeping, and audits of this, and that psychiatric assessment of a new patient should happen as soon as possible. Hume wasn’t seen by a psychiatrist, who was busy with other patients.

Coroner Bates also recommended that all staff carry duress alarms so vital time isn’t lost by staff having to rush to other parts of the ward to raise the alarm, as had happened in this case.

‘A reminder of what we’ve lost’

Hume’s parents, Owen and Carey, say their daughter didn’t want to die, but when she needed help she was left alone.

They’ve also spoken about their frustration with the attitude of hospital management in the aftermath, which they felt focused on damage limitation and denial rather than openness and accountability.

The pair, who live in Bay of Plenty, spent years doing their own detective work uncovering information, as Gray’s family did after his death too, and would travel to district health board meetings in Palmerston North.

They said Coroner Bates’ report was thorough and covered relevant issues well, but they were most interested to see if it would result in change to ensure nothing similar happened again.

“The findings are a reminder of what we’ve lost,” Carey Hume told RNZ. “Because people didn’t do their jobs, didn’t care,”

“I think that’s been the hardest thing to deal with - the betrayal to Erica by the ward 21 staff. You can dress if up anyway you like, but the bottom line is they didn’t care.

“Because if they’d cared, someone, out of all those staff on duty over two days, would have paid attention to Erica and sat down and talked to her and found out what was going on.

“And [if] they did know what was going on, done something about it, instead of just carrying on with the other things they deemed to be more important than saving a life.”

Carey Hume said she and Owen aren’t yet confident that change will be enduring, because improvements had come into effect over the years, but then dropped away.

They said 12 years later, the coroner’s findings are still relevant because the issues he raised covered problems happening now.

Carey Hume said the purpose of a coroner’s findings are to prevent or limit further deaths, yet the 2021 death on the ward shared similarities with what happened to Erica.

“You have to wonder if Erica’s case, and Shaun [Gray’s] had been progressed faster, then perhaps that death may have been avoided.”

Owen Hume said the 12-year wait for the findings was hard, but the worst part of the experience was the hospital not taking responsibility.

“That’s what’s been very hard. It’s been 12 years of never being out of your mind,” he said.

Carey and Owen Hume were now advocating for the creation of a public register of serious events at hospitals. It would update the progress on various recommendations coming out of reports and inquiries.

Presently, incidents were too often treated as individual events, they said.

“If they start doing this, then it’s going to have the ongoing effect on what the inquests are all about, of preventing the events happening again,” Carey Hume said.

Owen Hume said it would provide accountability so incidents weren’t hidden behind closed doors.

Carey Hume said in their daughter’s case if health decision-makers were serious about making improvements then they must implement all the coroner’s recommendations in full. Providing regular updates of progress on a public register would make them accountable.

Coroner’s recommendations accepted in full

Health NZ national director mental health and addictions Phil Grady told RNZ the organisation accepted the coroner’s findings, including all the recommendations.

“The service as it was 12 years ago and the service as it is today is quite different,” he said.

“Health NZ undertook, and the district health board at the time, it’s own internal review and identified a number of things that align with the coroner’s recommendations.

“We’ve moved to address the underlying issues that the coroner calls out.”

Grady said he had visited the new mental health ward at Palmerston North Hospital and spoken to staff and management.

“What I saw was a new, purpose-built mental health unit - a built-in environment with a range of safety features which weren’t in place at the time.”

Now, there is an electronic patient management system giving staff information from in-patient and community care, rather than the paper-based system in place in 2014.

Most ward patients are now checked every 15-minutes, and those in the high-needs area under observation every 10 minutes.

“There is an audit programme in place to ensure that we’re complying with that.”

That programme found there was compliance with this requirement, he said.

An audit programme would also ensure changes remain in place, as Health NZ worked through implementing coronial recommendations, including those made after Gray’s death. It had compiled a status report to show progress so far, Grady said.

Grady had offered to meet with the Hume family, where he said he would assure them he would personally oversee changes resulting from the coroner’s recommendations.

He said he was happy to discuss the idea of a public register of serious events and follow up actions with the Humes.

“This is a really tragic event and I want to acknowledged Erica’s parents and her family and friends. My thoughts are with them all.”

The coroner still has one final matter to determine.

The charge nurse on 6 May 2014 at the mental health ward has applied for permanent name suppression.

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, and English.
• Victim Support 0800 842 846.
• 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