Warning: This story discusses suicide.
The level of care for a Nelson mental health patient was sufficient and safe before he took his own life, a coroner has found.
Jacob Sharpe died in June 2024 while staying at a respite facility run by the community support service Pathways.
At the time of his death, Sharpe was under the care of Health New Zealand (HNZ) Nelson Marlborough following an acute decline in his wellbeing.
In findings released on Friday, Coroner Ian Telford said the 27-year-old had a longstanding and complex history of mental health, substance-use and personality difficulties, including "persistent suicidal ideation and several previous suicide attempts".
Police responding to Sharpe's death found notes which expressed aspects of his distress, thoughts about his life and experiences, frustration with his care, his regrets, and actions he had taken in the past, the report said.
Sharpe engaged with a counsellor from the Need to Talk? helpline over a two-day period in the week before he died.
"This chat commenced with Jake expressing active suicidal ideation and continued with the counsellor attempting to maintain engagement with him, while providing support and advice," the report said.
Sharpe's family raised concerns with Telford during the inquiry, particularly around communication between HNZ and Pathways and the suitability of respite care at the time of his death.
The report said Sharpe experienced chronic pain for many years, including headaches, neck, shoulder, limb and body pain.
"Various medications and other management approaches were tried. Jake repeatedly reported that only cannabis helped his pain," the coroner said.
During his final admission to Pathways, Sharpe reported the prescribed medicinal cannabis had become too expensive for him.
"Ultimately, the cause of Jake's long-term (chronic) pain, which persisted until he died, was never entirely determined."
Sharpe's engagement with mental health services began in 2014 after his first suicide attempt.
"Notably, during this episode, Jake reported using cannabis and longstanding bullying.
"He was seen by a psychiatrist in April 2014 and diagnosed with major depressive disorder with anxiety symptoms and commenced on medication."
Sharpe would receive ongoing treatment over the ensuing years as his mental health fluctuated.
Pathways said Sharpe had seven stays at the same respite care facility, from 2022 to the time of his death.
"In 2022 there was one stay for five days. In 2023 there was one stay of six days duration. In 2024 there was five stays between two and four days. All but one was initiated from emergency mental health services," the report said.
During his first stay he warned staff of the risk of self-harm, and asked them to remove items from his room.
The report said Sharpe was referred into respite care three days before he died.
"In the referral it was ticked that there was a clear plan that identified risk and strategies to manage this risk."
The next day Sharpe was reviewed by the HNZ Crisis Team as part of standard reviews for patients in respite care.
The report said HNZ mental health services were engaged in providing care and support to Sharpe throughout his life, as did Pathways from February 2020 to May 2022, including the provision of respite care from 2020 until the time of his death.
"I find that, overall, those involved in Jake's care at Pathways were appropriately cognisant of the clinical risks he presented," Telford said.
"The information available to them, together with their institutional knowledge of Jake, meant that they were well aware of his risk of suicide and responded appropriately to those risks during his time at the facility."
The coroner said HNZ Nelson Marlborough clinicians appropriately assessed Sharpe's needs and responded to Pathways' requests for him to be reviewed during his time in respite.
He agreed with Pathways' assessment at the time that respite care was a safe place for Sharpe to be.
"While recognising that suicide risk is inherently difficult to predict, and acknowledging the complexities and nuances involved in clinical assessment and planning, I find that the evidence does not support a conclusion that alternative decisions regarding Jake's care would have prevented his death," Telford said.
The coroner made no recommendations.
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.
If it is an emergency and you feel like you or someone else is at risk, call 111.
This story was first published on rnz.co.nz
