Paul Rowe died on 14 June, 2021. Photo: Supplied
WARNING: This story contains reference to self-harm and suicide.
A coroner has apologised to the family of a man who died after he was injured when he fell two storeys out a Palmerston North Hospital window over delays in the case.
The coroner has also ordered Health NZ to rewrite a report outlining what happened and what improvements in care have resulted, so he and the family could digest it.
Paul Rowe died on 14 June, 2021, six days after he fell or jumped from the window and lay injured and cold on a balcony for about two-and-a-half hours before he was found.
He was recovering from surgery for a serious, self-inflicted wound. The hospital has treated his death as a suspected suicide, although his family has raised questions about this and the fact he wasn't "sectioned" under mental health legislation on arrival.
Coroner Ian Telford began a case management conference on Tuesday by apologising for the time it's taken for the 58-year-old's death to wend its way through the coronial process.
He told Rowe's family that it seemed to have stalled some time ago.
"I want to apologise on behalf of the court for that. It simply should not happen," he said.
"What I can assure everybody is that I prioritised this matter when it came to me from the chief coroner and I will progress it robustly."
Coroner Telford said he had received some information from Health NZ, including a serious adverse event report, but found that hard to follow.
Rowe's family too reported problems with receiving information from Health NZ, including 180 documents that were not ordered or provided without any context.
The coroner ordered Health NZ to produce another report over the next eight weeks, written in plain English so he and Rowe's family could digest it.
It was to look at Rowe's clinical care, what policies and procedures were in place, whether there were any deficits in his clinical care or with hospital security, if any improvements had since been made and if any were still needed.
"The central question in this inquiry is apparent and agreed - that the care provided to Mr Rowe in the time proximal to his death at Palmerston North Hospital requires further inquiry," Coroner Telford said.
"Members of Paul's family have raised significant issues of concern about those care episodes and seek to understand them fully, as do I."
The coroner also ordered a pathologist to produce a report looking at whether Rowe's injuries when he fell or jumped were survivable if he were found sooner.
Rowe was admitted to hospital on 6 June, 2021, with a serious self-inflicted wound.
He was initially seen at the emergency department, before moving to intensive care, where he was under one-to-one care.
However, after his surgery he was transferred to a hospital ward, where he was checked on every 15 minutes.
When it was noticed he was missing from his room it was assumed he wouldn't have fitted out the gap in the window, and he wasn't discovered for about two hours and 40 minutes.
Hospital security also thought it had found him outside and that he returned to the ward unharmed, but this was a different person.
Rowe's sister Lisa Stevenson, who flew to New Zealand from Australia to attend Tuesday's conference, said she was concerned that nothing had changed at the hospital since 2021, and other people were at risk.
She said in the years since there had been a further death in similar circumstances.
RNZ understands that early last year a man was admitted to the hospital with a self-inflicted injury days before his death, and was subsequently prevented from attempting to self-harm by the same means in which he died.
On Tuesday Coroner Telford also made directions about disclosing evidence to different parties and said he would in early December decide when a further conference would be called.
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.
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