‘Like watching him drown’: Family fights for change after son’s death

Saturday, 22 February 2025

For 14 years, Sue Birdsall felt reassured by a one-page apology letter sent the last time her son Warwick walked out of Wellington Hospital’s mental health unit.

Nothing could erase the awful memory of her hungry and desperate son bailed up by a police dog and handcuffed five days later, or the toll the rough sleeping and abruptly stopped meds took on Warwick’s recovery.

He had been moved from the unit’s secure ward without family input. Two weeks later it happened again.

But as she helped Warwick push through years of bed-bound depression, manage to hold down a job and live a relatively normal life, Sue clutched at the belief that if the illness reared again, she would be heard.

“I apologise … for what happened during Warwick’s recent hospital admission,” mental health director Nigel Fairley wrote way back in 2010. “Particularly for the lack of engagement with the family, and want to reassure you that you will be involved in future decision-making with Warwick.”

Now, she feels that promise wasn’t worth the paper it was written on.

“For 14 years I felt safe because I had the letter. What a waste of time it all was.”

‘It was like watching someone drown’

Warwick Birdsall went from bright and fizzy nipper to deputy head boy at Wellington College and first XV vice-captain, trouncing a Jerry Collins-led St Pat’s team by punting four penalties in a howling southerly.

He was good at rugby, good at skiing, good at school, apparently good at life.

But his 20s turned on him. University wasn’t for him, so he set up a building business. That got into financial trouble, and in 2007 Warwick tried to break into an eftpos machine. That led to his diagnosis as bipolar.

Those were dreadful years, says Sue. He was committed for compulsory treatment twice ‒ once in Invercargill and that second time, in 2010, at Wellington Hospital.

But with the help of family and an excellent community mental health nurse and psychiatrist, Warwick found a way through, and the demons departed.

“He had electric shock treatment, which made a huge difference. Until finally, we could see his life was like yours and my life. But it took perhaps three years. Depression is awful beyond belief.”

Warwick became a licensed builder and for 10 years he was well ‒ a mental health success story. He lived at home with his parents in Brooklyn, revelled in family ski trips with the nieces and nephews, bought a vintage 1928 Dodge with Sue and tripped to the Art Deco Festival in Napier.

“We filled up nine times once,” Sue laughs. “It was what we did on a fine day.”

But at the end of 2023, she started noticing little deteriorations ‒ hints of the delusions returning. Warwick was struggling with long Covid, and something went wrong at work.

“I just sensed something, until February, March, I realised Warwick wasn’t well again. It’s just incremental.”

Then a builder colleague called to say he hadn’t turned up to work for seven days.

That was a huge red flag, so Sue called Warwick’s GP, who wouldn’t tell her anything, citing patient privacy. She called on the mental health crisis team, over and over, to help. But nothing happened.

On Easter Saturday ‒ March 30 ‒ Warwick became convinced someone had messed with his beloved t-shirts.

“This is how edgy they become. They get so worked up, it’s unbelievable … We can’t understand how complicated it is for a complicated brain. If Warwick worried about something, he can’t laugh it off.”

That same day, he left home. He stayed in motels, checking in by daily texts, which often sounded confused.

Again Sue tried to get help from Warwick’s GP, police, the crisis team. They would check up on Warwick, he would say he was fine, and round and round they’d go.

“He was always cross with me that I hadn’t respected that he was OK, when of course, I knew he wasn’t OK.”

She even reported him missing, in case that was necessary to get him committed.

As Warwick’s father Rex points out, by then the couple had more than a decade of experience navigating the mental health system. Yet still they couldn’t convince anyone to intervene.

“When it all started, we had bugger-all knowledge of mental health ‒ it was terrifying,” Rex says. “But now we know so much more. And yet we were absolutely powerless to help him, when we knew where it was heading. And the system just stymied us at every bloody step.”

After a “soul-destroying” call with the crisis team on April 5, where she felt “berated”, and ignored, Sue gave up.

“You can only try so hard to do something. I couldn’t have tried harder, I don’t think. It was like watching someone drown, and that’s what it was like for six weeks.“

A near miss, and hope of help

On Tuesday May 14, 2024, Warwick sent Sue a message she took to be a goodbye text. He thanked her and said he’d transferred $60,000 into her account. Her voice snags at the memory.

Thinking the fog must have lifted long enough for Warwick to suddenly see he was unwell again, Sue immediately rang 111. She knew he would be at his most vulnerable ‒ devastated to realise his brain had again been playing tricks.

Fourteen searchers and the police launch found him at Red Rocks on Wellington’s South Coast the next day. He was alive but spent.

“That’s when I knew that Warwick wasn’t there any more. He was just like a little shadow of this lovely person.”

But the near miss also spurred hope, as Warwick was ferried to hospital.

“It was our chance, finally, to get him the help that I had fought for over the previous two months.”

Sue thought Warwick would be assessed, her input would be sought, and he would be made a compulsory patient in the hospital’s secure mental health ward, where he would be safe.

“He would have been protected from himself, because he had been twice before. And that’s what I thought would happen.”

But she says she was never asked to contribute; never had a chance to mention the suicide text. Instead, Warwick was assessed as not needing compulsory treatment under the Mental Health Act, and admitted to the less secure part of the ward.

Two days later, Warwick’s psychiatrist called to say he had walked out of the unit. He was found on Mt Victoria with catastrophic injuries, and died on May 22 in intensive care. He was 44.

A long and tragic history

Warwick joins a sad parade of patients who have walked out of Wellington Hospital’s mental health unit into tragedy.

In February 2003, a patient left the unit and climbed into Wellington zoo’s tiger enclosure, where he was mauled.

In July that year, Chad Buckle went AWOL and was found dead in Wellington College grounds. In his report into Buckle’s death, Coroner Garry Evans said: ”What happened on this occasion should never be permitted to happen again.“

But just a year later, Chris Canham climbed out a tree and jumped six storeys, causing lifelong injuries. And in 2012, Zubidullah Abdullah scrambled over a wall to his death, leading Evans to repeat again: 'There should be no more escapes from the Board's mental health care.“

And that’s just the ones we know about ‒ Warwick’s 2010 flight did not make the news.

The unit got a $7.8 million overhaul in 2012 to make it a less forlorn and foreboding environment. But there have been more deaths since. In 2015, Samuel Fischer was found dying in his room, and in 2017, Mario Cribb died while in the unit’s legal care.

A 2020 inspection by the Office of the Ombudsman found the unit was frequently overcrowded and understaffed, with seclusion rooms being inappropriately used as bedrooms. More repeat recommendations.

The Birdsalls’ former tenant Chris Street, who knew Warwick from childhood, has been supporting the family through the hospital’s review into his death. A lawyer who also worked with the Buckle family, he’s incensed at the fact little seems to have changed in 20 years.

“How is this hideous experience going to lead to anything different from the failures to date?” he asks in his submission to the review. “Mental health failed Warwick in the most fundamental way. Equally, it failed Warwick’s family and friends. The failure has been catastrophic beyond words. A beautiful human being is gone. His family is distraught and bereft. And all of this was entirely avoidable.”

How do you make mental health units safer?

Health NZ mental health clinical director for Capital and Coast, Hutt Valley and Wairarapa, Paul Oxnam, says he is “deeply sorry” for Warwick’s death and the loss and grief his family has experienced.

However, he failed to answer several of The Post’s specific questions around Warwick’s care and death, including whether the 2010 apology letter promising family involvement was available on his file, and whether the service considered it had lived up to that promise.

Asked whether security is stepped up to safeguard patients such as Warwick, who are a known flight risk, Oxnam says those patients can be treated in more secure areas. However, he confirmed that Warwick was cared for in the less secure part of the unit, and was not a compulsory patient.

While tighter restrictions can be imposed when patients are committed for compulsory treatment, that infringes considerably on a person’s autonomy and is a last resort, Oxnam says.

“While restrictive measures to enforce treatment can be justified in limited circumstances, contemporary mental health practice recognises that such measures can themselves cause considerable harm and that they must be used only when no safe alternative is available and only for as long as absolutely necessary.”

Following Warwick’s death, access to the unit’s courtyard is now more tightly controlled, Oxnam says. Any recommendations of the Serious Event Review into his death will be taken “very seriously” and further changes may result, he says.

How people are dealt with in mental health crises is under review, with a planned replacement to the Mental Health Act. Some submitters have called for an end to seclusion and restraint, and others want to end compulsory treatment altogether.

Street, however, argues Warwick’s death is a clear example of why it’s needed to keep people safe.

Only a fraction of people experiencing mental illness ever end up in acute mental health units, and not all of those are compulsory patients under the Mental Health Act.

In 2022/23, 11,000 people were placed under the act to have compulsory assessment or treatment, but that can be in the community or in a hospital unit. That’s 6.2% of the 178,520 people who got specialist mental health and addiction services that year.

“We’re not talking about many people, but for those people, these places are vital, and they depend on them,” says John Moore, CEO of mental health family support organisation Yellow Brick Road.

“It needs to be a place where people get well, but the security is also a factor in that wellness.”

Units should be able to be designed so they’re secure, without feeling like a prison, Moore says. But overstretched staff are also a common worry raised by families.

Engagement and insights manager of consumer voice organisation Changing Minds, Megan Elizabeth, can’t comment on whether inpatient units should be made more secure, except to say patients have the right to a safe, culturally appropriate environment that looks after their physical health, treats them in a way they want and does not cause further trauma.

“That currently feels like it’s a long way on the horizon for a lot of people.”

Some also question whether a truly transformative mental health system would even need a compulsory treatment act. And people want more focus on other areas of their lives that affect their mental health, Elizabeth says.

“People really want earlier supports, more wraparound supports, more community-based supports.”

Family input versus patient privacy

Families can be complicated things. But they’re also the largest mental health providers in the country, argues Moore.

“When we are overwhelmed, when the thinking part of our brain is switched off because the emotional part of our brain is running amok, we need to borrow someone else's fully functioning frontal lobe in order to be able to get back to calmness, normality and be well again.

“And for most of us, it's going to be the people that we live with, that are closest to us in our life, who we lean on, when we're in that period of struggling.”

But like the Birdsalls, families often feel shut out and talked down to, Moore says. They’re overwhelmed and exhausted from caring, or trying to get help, and at the same time feel pitted against medical experts and sometimes their loved one.

“It’s easy to get trapped in a cycle of confrontation and that can drive a wedge between families.”

Families need better support to keep themselves well and to advocate. And they need recognition that the insights born of spending a lifetime with someone are valuable, Moore says.

He wants to see advance directives, so people can make decisions when they’re well about who they want included in their care in times of crisis.

That’s something Elizabeth also supports. While the proposed Mental Health Bill would introduce advance directives for compulsory care, she’d like it broadened to all acute care.

“So that in the time leading up to an acute event, there is a guideline written by the individual, with the support of those they trust, around how they can best be supported through moments of distress.”

Talking to people who have experienced suicidal thoughts, their whānau members and families bereaved by suicide, all agree that families need more support to help loved ones through mental distress, Elizabeth says.

Oxnam says their policy is that, wherever possible, whānau should be involved in the care of loved ones undergoing specialist mental health care.

Sue gave up the 1928 Dodge she shared with Warwick, now he’s no longer there to drive it. But she’ll remember those sunshine-filled jaunts. And Warwick perched at the top of a skifield, about to let loose down an expert run.

People ask her what’s the point of speaking out. The answer is in her submission to the review into Warwick’s death.

“All I had ever wanted was for Warwick to be safe … That he had the freedom to so easily walk out while he was in the care of MHAIDS [mental health services] … and do the damage to himself that led to his death is appalling.

“Warwick was a huge part of my life. His death has devastated me and I am left with huge concern about all aspects of mental health and how it is dealt with in New Zealand.

“Friends and family ask me what I hope to achieve in writing this submission.

“What I hope is that you will learn to listen.”