Nurse's name revealed in student death case at mental health unit

By Jimmy Ellingham of RNZ

A name-suppression order for one of the nurses responsible for the care of a 21-year-old student who died by suicide at a mental health ward has lapsed.

Erica Hume died in May 2014 at Palmerston North Hospital, a death Coroner Matthew Bates ruled as preventable and could have been avoided if staff had correctly followed policies and procedures.

He also found staff were under pressure due to the high number of patients and that the ward’s physical environment wasn’t fit for purpose. A replacement ward opened last year.

During an inquest into the death in 2022, temporary name suppression orders covered healthcare workers. When the coroner’s ruling was released in June these orders lifted, except for one covering registered nurse Donna Jo-Anne Jones.

She was granted temporary suppression to allow her to consider an appeal against the coroner’s ruling against her application for suppression.

She had until 31 July to do this but the Coroner’s Court and the High Court have confirmed no application was received.

Erica Hume’s parents, Carey and Owen, said they were pleased to see the order lapse.

In a statement to RNZ, they said: “Open justice does require people to be named and applications for a permanent non-disclosure order should be declined if there is truly to be embedded change in mental healthcare within New Zealand.”

Coroner Bates’ ruling declining Jones’ application for suppression said she cited interests of justice and personal privacy in arguing her name should remain secret. The coroner has ruled the specifics of her argument are suppressed.

Jones, who could not be contacted, managed Erica Hume’s admission to the Palmerston North Hospital mental health ward, known as ward 21, on 6 May 2014 and nursed her that evening. Erica Hume died the next day.

The coroner found that despite Erica Hume’s care worker giving a “detailed and diligent verbal handover”, Jones did not take on board the heightened risk of suicide.

She also failed to adequately review admission information in Erica Hume’s clinical file and record that information on admission documentation.

Coroner Bates said: “These failures meant that from the time of admission to ward 21, Erica’s heightened risk of suicide... went either unrecognised on the ward or, at the very least, the severity of her risk was not appreciated.”

He said this affected the care Erica Hume received, including the levels of observation she was under, and the following shift wasn’t fully appraised of the situation.

The coroner said Jones believed she did the best she could in the time available, writing in Erica Hume’s file: “Admission paperwork to complete. Due to ward activity, unable to do.”

Jones did not alone bear responsibility for Erica Hume’s death and no individual was singled out for criticism in his findings, the coroner said.

He added: “The role she played occurred in the context of widespread systemic failings and resourcing shortfalls at ward 21, including prolonged staff shortages.”

Jones has been a registered nurse for almost 20 years and still works at Palmerston North Hospital.

Erica died as a result of a self-inflicted incident at Palmerston North Hospital. Photo / Hume family

Carey and Owen Hume said after Erica’s death they encountered a hospital system “embedded with non-disclosure” and a “deep-seated expectation of non-accountability”.

They said: “It is our opinion that accountability is a major factor in the examination of the care of Erica, and this includes the actions or inactions of all parties, staff and management.

“It is also our opinion that the purpose of having an inquest is to determine what happened and try to ensure that there is no repeat of the circumstances that allowed it to happen.

“This means, too, that individual as well as collective responsibility and accountability must occur.”

They said for too long it was assumed healthcare workers would receive name suppression because it would harm their therapeutic relationship with patients, which was a a poor excuse.

They added: “We firmly believe patients and families have the right to informed consent and knowledge of whom they are entrusting their care to.”

The Humes said there was public interest in naming Jones, and her not seeking to appeal against the coroner’s ruling could be a sign she was taking responsibility for her role in what happened - which they said wasn’t minor.

They said: “This not a vendetta against a particular staff member. This is about wanting embedded change in the attitudes of staff and management within the mental health service.”

This story was first published on rnz.co.nz