A coroner is recommending better recording of information provided by any family member or anyone else about a person suspected of being suicidal, following the death of a a Bay of lenty woman.
Coroner Michael Robb has made recommendations that police could have better recorded information provided to them about a suicidal woman's mental state.
The recommendations follow the death of Karen Day, a 59-year-old mother and grandmother, in October 2016.
In his just-released report, coroner Michael Robb says the police who dealt with Ms Day before her death could have better recorded information her whanau had provided them about her mental state.
Michael says that information should have been passed on, in full, to the nurse who came to carry out a mental health assessment.
In late September 2016, Karen left her home in Taneatua during a family dinner and went to see her husband who she had recently separated from.
The pair discussed their relationship civilly and Karen left in her car.
A couple of hours later, Karen texted a number of family members, including her husband, telling them she had made the decision to end her life, despite their wishes that she not do so.
Her husband reported this to the Whakatāne Police Station and he showed the officers the messages.
Karen had earlier called Lifeline in a distressed state, and police were also alerted to this.
Family members and police officers headed out in search for her.
The coroner says police officers tracked her down "driving at speed" through Edgecumbe, but she failed to stop for their flashing lights and sirens.
Road spikes ended up being used to stop her car.
Before she was taken to the police station, the coroner says in his report that Karen was asked a number of questions by officers and she told them she wanted to take her own life and "wished to be asleep forever".
Officers arranged a mental health assessment for Karen and a registered nurse from the Bay of Plenty District Health Board came in.
Following the assessment, Karen refused to be admitted to the Whakatane Hospital for mental health care.
The nurse decided, based on the evidence she had gathered, that she didn't meet the criteria for compulsory treatment and Karen was taken home by family members.
The next day, Karen was visited by a mental health nurse. Due to an oversight, a follow-up visit the day after that never happened.
Later that afternoon, Karen was found unresponsive and taken to Whakatāne Hospital.
She was then transferred to Tauranga Hospital where she died 12 days later.
Michael found that the nurse who did the mental health assessment at the police station wasn't provided with all the relevant information about her state of mind.
Karen didn't reveal her level of determination to end her life to the nurse.
Because Karen would not voluntarily be admitted to hospital, a compulsory care order would need to have been made.
Michael says had the nurse had access to all of the police information and seen the text messages sent to family members, or interviewed those family members, a different decision may have been made.
But even if Karen had been assessed as requiring compulsory care, Michael says it might not have been possible to save her life.
Karen's son, Eddie Sykes, says the whanau is relieved it was not found to be at fault.
"Having that recognised was probably the most reassuring and comforting part to know that we did all as a whanau we could to help her."
Eddie says the coroner's inquest wasn't about finding personal blame, rather it was about helping to ensure that there are training, systems and procedures in place to reduce the chances of future deaths occurring in similar circumstances.
Michael has made three recommendations to improve the way people are assessed for mental health care or other treatment at a police station:
• The police record in as much detail as possible all information provided by any family member or anyone else about a person suspected of being suicidal
• Where the police have called on the professional assistance of a service provider to undertake a mental health evaluation of an individual in their custody, that they provide as much detailed information as they have available to them about that individual and the circumstances that led them to be in custody
• In undertaking a mental health assessment, the information provided by the person being assessed be critically evaluated by reference to other sources of information, be it through the interview of family members, reviewing text messages, or seeking out information recorded by police officers directly involved with the individual.
In a statement, police say they would take time to consider the coroner's report.
The Bay of Plenty District Health Board says the findings have highlighted the importance of corroborating and sharing information to ensure the best interventions are provided to every person.
It says the findings have been taken on board.
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
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). 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 (24/7)
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email firstname.lastname@example.org
What's Up: online chat (7pm-10pm) or 0800 WHATSUP / 0800 9428 787 children's helpline (1pm-10pm weekdays, 3pm-10pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.