Death raises fears for others in Ward 21

21:14, Aug 17 2014
Shaun Gray
MISSED: Shaun Gray.

The family of a man who died in Palmerston North Hospital's mental health ward say they fear for the lives of other patients.

Shaun Gray, 30, died in what the Manawatu DHB has described as an "apparently self-inflicted death" in Ward 21 on April 16.

His parents, Ian and Christine Gray, and brother Ricky, said systematic failures within the mental health service and staff negligence contributed to his death, and a "drawn-out, reckless" process since the death had left them with no trust in the DHB and no chance to grieve.

Christine Gray
LOSS: Christine Gray and family say they have lost faith in MidCentral mental health services after their son Shaun Gray died in the mental health ward of Palmerston North Hospital in April.

Ricky Gray said his family could not understand how his brother could be allowed to die in the hospital's mental health unit.

"He was placed in there under the Mental Health Act and there were a lot of messages stating what his state of mind was and he should really be under constant care, and then later on he's dead," he said.

A draft root cause analysis (RCA) obtained by the Manawatu Standard details the events surrounding Gray's death.


The RCA report identifies seven factors that contributed to Gray's death, including failure to complete a new risk assessment on his admission to Ward 21, an incomplete and informal handover process, failure to recognise him as high risk, and failure to observe him every 10 minutes, as per procedure.

Gray was admitted to the hospital's emergency department on April 15 by the DHB's Alcohol and Other Drug service team and restrained and sectioned under the Mental Health Act before being transferred to the High Needs Unit of the mental health ward the next day, the report said.

"A risk assessment highlighted that Shaun was a serious risk to himself . . . and exhibiting current self-harm risk behaviours."

The process from when he was transferred from the emergency department to Ward 21 "wasn't right", Ian Gray said.

"From that time onwards things are just a complete shambles."

The report said "it could be surmised" that Gray's clinical notes were not read at any point during his time in Ward 21.

"There were approximately 16 entries in [his] clinical notes from emergency department staff relating to suicidal ideation. At no point was this handed over."

The report also said observation of the patient, which is required every 10 minutes, was not adhered to.

"It would appear [Gray] was not observed for at least 45 minutes ... there is no documented evidence identifying the last time [he] was observed.

"Of great concern is the fact that [he] had placed a bed sheet over the observation window of his room, obscuring the view of staff to assess [his] safety . . . the sheet was observed by staff but not removed."

Ricky Gray said the family believed and understood his brother would be under careful supervision in the unit.

"They haven't just not followed process, they've blatantly ignored aspects of their role, for example observations would be an obvious check when you're assigned to a ward, it's complete negligence."

Christine Gray said the whole process had been cold and uncaring.

"To be honest I wouldn't even consider putting anybody that I cared about in that unit at the moment, I just wouldn't. I'd be scared for their safety because things are still happening in there that are wrong.

"We just want the thing fixed, that's all we want."


Lifeline - 0800 543 354

Depression Helpline (8 am to 12 midnight) - 0800 111 757

Kidsline (aimed at children up to 14 years of age; 4 pm to 6 pm weekdays) - 0800 54 37 54 (0800 kidsline)

Suicide Crisis Helpline (aimed at those in distress, or those who are concerned about the wellbeing of someone else; 12 noon to 12 midnight) - 0508 828 865 (0508 TAUTOKO)

Youthline - 0800 376 633, free text 234 or email

Samaritans - 0800 726 666 - visit the website, email or free text 5626 (emails and text messages will be responded to between 12 noon and 12 midnight). 

Manawatu Standard