Warning: This story contains discussion of suicide

A woman who died in Tauranga Hospital’s mental health ward told staff she was “triggered” by equipment in her room, but nothing was done, an inquiry has found.

And prior to being found unresponsive, Vanessa Bishop hadn’t been checked for almost two hours, despite supposedly being on 15-minute observations.

Her mother, Janey Bishop, said she was “horrified, angered and frustrated” that Vanessa died as a result of what appeared to be a “lack of common sense”.

She says the family will make a complaint to the Health and Disability Commissioner.

“Someone needs to be held to account for this,” Bishop said. “It breaks my heart that there was such a litany of errors that led to Vanessa’s death.

“What Vanessa went through shows just what a dire state our mental health system is in.”

Bishop, 30, who featured in a 2015 Stuff story about care of psychiatric patients in the community, died in the hospital’s mental inpatient unit, Te Whare Maiangiangi​, on December 2 last year.

A coroner is yet to rule on the cause of death, but it is being treated as a suspected suicide.

The death sparked a “serious incident review” by a team of senior mental health experts from other regions and a series of recommendations were made to improve systems and care.

Te Whatu Ora Health New Zealand says it has either implemented, or is in the process of implementing, the recommendations. But it denies the failings directly caused Bishop’s death.

The review report, obtained by Stuff, shows Bishop was known to hospital staff, having been admitted 16 times over the past decade.

Bishop had been at the unit for about 26 nights and was in the process of being transitioned to community care when she died.

She first presented at the hospital’s emergency department on October 17. She was discharged, but presented to the emergency department (ED) again the following night.

There were no beds available in the mental health unit, so she was kept in the ED. On one occasion, she was found unconscious and resuscitated.

The “working diagnosis” was post-traumatic stress disorder, functional neurological disorder and temporal lobe epilepsy. Bishop was also using a wheelchair because of pain in her leg.

The report says that Bishop was admitted to Te Whare Maiangiangi on October 20.

Two days later, she was moved to the unit’s secure, intensive care ward.

She stayed there for about 12 days and appeared to be improving, so was moved back to the open ward and allowed escorted leave with her carer.

However, her mood remained low and on November 12 she deliberately burnt her arm with boiling water from the kitchen,required a transfer to Waikato Hospital for skin grafts, the report says. She returned after 10 days and her mood seemed to have improved.

A few days before her death she told one of the psychiatrists she felt “triggered” by equipment in her room.

On her last day alive, she told a psychologist she was ready to transition home, although she was in pain from the skin grafts.

Doctors discussed her transition plan and agreed she was a “high risk” patient who needed intensive support in the community.

The report says that because she was considered a high risk of self harm and suicide, Bishop was on “level two observations”, meaning she was supposed to be checked in her private room every 15 minutes.

The inquiry found this wasn’t adhered to the night she died. No observations of Bishop were recorded between 10.30pm and 11pm, and that was the same for two other patients on level two observations, the report says.

After 11pm, observations were reduced to hourly, which was customary practice in the unit, although against policy.

Bishop was observed to be asleep every hour until 3am, when no observation was recorded. The last recorded observation was at 4am.

At 5.50am staff found Bishop unresponsive. Resuscitation attempts were unsuccessful and she was declared dead.

Bishop had a “safety plan”, the report says, that noted removing items that made her feel “risky” would make her environment safer.

Bishop had told staff she would use the equipment in any suicide attempt. She’d even requested that her room be locked when she wasn’t in it, “to reduce the temptation to use [the equipment] to self-harm”, the report says.

Despite this, the investigators found, no actions were taken by staff to assess the equipment for risks and to reduce the likelihood of self-harm, such as increasing observations.

A Te Whatu Ora spokesperson said recommendations by the review team had been actioned or were underway.

These included improving safety around the equipment involved in Bishop’s death, staff training to emphasise the recording of new risks during a patient admission and changes to patient observation practices.

Janey Bishop said if her daughter had been checked as frequently as required she might not have had time to take her life, or could have been resuscitated.

“To know that she had been left without being checked for almost two hours is heartbreaking.”

She said Vanessa had spoken openly to staff about feeling triggered by the equipment in her room.

“She wasn’t listened to, and people appeared blind to the risk that was right in front of them.”

Vanessa had worked as a patient advocate, and the review found she had spoken to a nurse the day before she died about doing an educational video for medical students about better care for mental health patients.

“She advocated so hard for change in the way consumers of the mental health service are cared for and respected,” Janey Bishop said.

“I just want to make sure that the change she so wanted takes place and becomes permanent.”

Where to get help

• 1737, Need to talk? Free call or text 1737 to talk to a trained counsellor.

• Anxiety New Zealand 0800 ANXIETY (0800 269 4389)

• Depression.org.nz 0800 111 757 or text 4202

• Lifeline 0800 543 354

• Rural Support Trust 0800 787 254

• Samaritans 0800 726 666

• Suicide Crisis Helpline 0508 828 865 (0508 TAUTOKO)

• Yellow Brick Road 0800 732 825

• thelowdown.co.nz Web chat, email chat or free text 5626

• What’s Up 0800 942 8787 (for 5 to 18-year-olds). Phone counselling available Monday-Friday, noon-11pm and weekends, 3pm-11pm. Online chat is available 3pm-10pm daily.

• Youthline 0800 376 633, free text 234, email talk@youthline.co.nz, or find online chat and other support options here.

• If it is an emergency, click here to find the number for your local crisis assessment team.

• In a life-threatening situation, call 111.