The coronial inquest for 20-year-old Ross Taylor began at the Dunedin District Court on Monday, more than three years after the Health and Disability Commissioner released a report criticising the care he received.
The investigation found the Southern District Health Board and the treating psychiatrist both breached the patients’ rights code by failing to provide services with reasonable care and skill.
At the outset coroner David Robinson stressed that his inquiry, which was scheduled to last two weeks, was not to address "quality-of-care" issues or apportion blame.
His function was to determine Ross Taylor’s cause of death, circumstances of death and to possibly make recommendations to avoid similar scenarios in future, he said.
The court heard Ross had died on the night of March 21, 2013, and former friends and flatmates spoke about his erratic behaviour leading up to that point.
Ross Taylor’s parents Corinda and Sid spoke about a boy who was "confident, chatty, friendly and happy" through his childhood.
Corinda Taylor, who founded the Life Matters Suicide Prevention Trust after the tragedy, spoke of Ross showing early prowess as an athlete: skiing, skating, surfing, kick-boxing, golf; able to trounce her at squash by the time he was attending intermediate.
She told the court she only saw a change in him after his first concussion as a teenager.
There were changes in mood, behaviour, social activities, sleep, "easily confused with normal changes of adolescence", she said.
The delays in holding the hearing had repeatedly traumatised Corinda Taylor and she said she had gone on reliving the last week of her son’s life.
"I feel his pain and I feel guilt, that I missed the most important signs in my own boy. I blame myself I couldn’t keep Ross safe," she said.
After experiencing his first psychotic episode in 2012, Ross Taylor was admitted to Wakari Hospital where he was medicated and discharged.
And the family believed he was relapsing at the time of his death.
Whether he was or whether his erratic behaviour was the result of drug and alcohol use would be a major issue for the coroner to determine.
"I bear no ill will to anybody, I simply miss my boy. I loved him with all my heart. This has left a huge hole in my life," Sid Taylor said.
His wife hoped his legacy would mean lives were saved in future.
The first two days of the inquest heard solely from Ross Taylor’s former flatmates and friends.
Witnesses said he was sporadically using drugs and alcohol, and on one occasion put an LSD tab in his eye.
They gave evidence about a slew of strange incidents in the weeks leading up to his death which included Ross Taylor trying to set fire to his mattress and clothes, pouring paint down the street and skateboarding at speed while tugging a buoy.
Just days before his death he and friends attended a memorial for a friend of theirs who had taken his own life, the court heard.
Ross Taylor also created a number of drawings while in a "very animated state".
"They just looked like scribbles," one flatmate said.
"There was no substance to the pictures but he would talk as if there was great meaning."
He told others he was convinced there was a microchip in his brain through which his parents could control his thoughts.
Sid Taylor asked each witness whether they were aware his son had gone to Emergency Psychiatric Services in the early hours of March 12, just nine days before his death.
None were.
The aim of the inquest was to determine a range of issues including:
■ Was Ross Taylor suffering a relapse of psychosis (December 2012-March 2013)?
■ Was a suicide-risk assessment carried out in March 2013 adequate?
■ Should he have been involuntarily committed to a facility during the final weeks of life?
■ Was the reintroduction of anti-psychotic medication intended?
■ Would reintroduction of the drugs have reduced the risk to Ross Taylor?
■ Should mental-health-patient records be maintained in electronic format to allow clinicians ready access?
■ Did the Southern DHB’s perception of his parents inhibit communication?
