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“Is that a photo of Liam?” coroner Bruce Hesketh asked Geoff Booth as he took his seat at the witness stand.
It was the first day of the inquest into Liam’s death, held at the district court building, over two days last week.
“That is a photo of Liam,” said Booth of the framed black-and-white picture he had carried to the stand and placed next to him.
“Would you mind if I could see that? I have never seen what Liam looks like,” Hesketh said.
It was a touching moment in the two long days of evidence given by witnesses, who were mostly professionals involved in Liam’s mental health care, as well as his parents and police officers.
Liam was 21 when he was found dead in a park near his Beckenham flat on October 2, 2017. Booth has been fighting for answers ever since, riled by the failure of health services to save someone who was clearly suicidal.
“I want to look them in the eye, so they can see the end result of not doing their job correctly,” Booth told the Selwyn Times last year when talking about his battle to make sure an inquest would be held.
Finally, last week, his day in court had come. Sitting with the photo of Liam beside him, he put on a brave face to relay what happened leading up to his son’s death.
Just 18 days prior, on the evening of September 14, Liam phoned, crying and upset, saying he was considering taking his own life.
Booth said if he had not managed to find out where Liam was in that conversation, his son might have died that night.
“I spoke to him for quite a bit of time. I just said in passing ‘Where are you?’ and he said ‘Halswell Quarry’ and then he hung up.”
Booth phoned 111.
Police were called to the scene about 8.30pm and found Liam about 20 minutes later, sitting in his car. They took him to the emergency department at Christchurch Hospital.
About 10.30pm, a psychiatric registrar phoned him and said they were not going to keep Liam in hospital and outlined the reasons for this. His suicide risk had been assessed as low to moderate. Booth told the registrar there wasb no guarantee Liam would be safe and he wanted him to be admitted for compulsory care.
“I said ‘I think he still has suicidal thoughts’, and he only had to get it right once.”
He told the registrar to give him an hour to get there to pick him up. But then the registrar said Booth had misunderstood him, and they had already let Liam go, paying for a taxi to take him back to his flat.
“I was absolutely furious.”
Booth tried to phone Liam but he was not answering his calls. He got in his car and drove to Christchurch, then around the city looking for him.
“I couldn’t find him for the entire night.”
Booth said during the year prior to this night, he had continually been in contact with health services about Liam’s well-being and state of mind. He would attend GP appointments with his son, and talk to the Canterbury District
Health Board’s mental health services’ crisis management team.
“It was almost like watching a train wreck. There was more and more involvement from me and he needed more and more support leading up to his death,” Booth said.
“You don’t know what you don’t know. Now I know a lot, but it doesn’t help Liam. There were breadcrumbs all the way through this. If someone was able to have a look holistically over the whole file of Liam, there were signs, and the signs just weren’t reacted on,” Booth said.
“It would have been nice if they had contacted me before Liam had died. They contacted me after, six months after,” Booth said.
“I was his support person, but I didn’t know what support was available.”
Booth said he saw in Liam’s medical notes after his death about incidents of suicidal ideation previously, but none of these had been disclosed to him when Liam was alive. He also had not known about Liam’s use of drugs. In retrospect he could see that by the night of September 14, Liam had not been able to make rational decisions for himself, yet he was sent home “unsupported” within one-and-a-half hours of arriving at the hospital.
Booth did manage to find his son on September 15, and went with him to a GP appointment.
He said the last time he saw Liam was October 1, the day before he was found dead.
Liam had driven to Sumner and phoned to ask Booth to come and see him. They chatted in his car for about 20 minutes. Liam told him he had been discharged from the care of the health board’s crisis management team as an outpatient. Liam had become an outpatient of the team following his emergency department assessment on September 14.
“He said to me: ‘I am not right, I am not right in the head. And they have let me go’,” Booth said.
He said Liam was aware he had drug and alcohol counselling coming up, and was planning to buy ham on the way home to make a sandwich for work the next day.
“That gave me some confidence he was still functioning.”
He checked in with Liam later in the day, phoning just after 5pm, and everything was okay.
“And that was the last time I spoke to him.”
He said while there had been no warning signs on that day, something must have “materially changed” later that night to flick him back to suicidal thoughts.
Liam’s mother Debbie Bree gave tearful evidence via video link from her home in Dunedin.
Liam was her second son, born in 1996. He lived with her until moving to Canterbury to live with Booth when he was 11. His childhood behaviour, including a threat of suicide, had prompted her to seek the help of medical professionals. He was diagnosed with adjustment disorder and oppositional defiance disorder.
She also spoke to him by phone on October 1.
While he was calm and seemed fine, she thought he was having issues with his girlfriend and wanted the relationship to be better.
“I said ‘Give her some time, don’t ring her all the time’. I wanted him to see beyond the next hour, give her a day, then take her out for a coffee. He can’t see beyond the next 10 minutes.” She was trying to assure him life would be good again.
In hindsight, she thought if he had not taken his life that night, he may have done it another time.
“He was a sensitive young man, he didn’t have control of his emotions,” Bree said.
“I feel so awful that he had such a hard time throughout his life. Our loss is so devastating, it never goes away.”
In 2018, the Canterbury District Health Board formally apologised to Booth, for the fact Liam died while under its care. The health board also undertook a serious event review, which suggested family members should have been
involved in a discharge plan, and they would have benefited from more information about support. Booth has also lodged a complaint with the Health and Disability Commissioner.
The purpose of the inquest is to establish the facts of what happened in the death. As part of that, the coroner is addressing whether the level of care Liam received from the health board was appropriate, and whether there should have been a formal assessment of him under the Mental Health Act. He may make recommendations in his findings to help prevent similar deaths in the future.
On day two of the inquest Hesketh had probing questions for Booth and the health board’s medical personnel who dealt with Liam.
Booth told the coroner he struggled with the fact that when the crisis team would phone Liam, it was from a blocked caller ID. This would mean he didn’t know who he had missed a call from. The team would then make a record of him not engaging with services.
“As far as I understand, that is still the process now, five years later. There will be a lot of kids who don’t have credit on their phone, they don’t know who they missed a call from.”
A youth drug and alcohol counsellor from Christchurch City Mission, Brian Johnson, who saw Liam, told the coroner that in the case of people not attending a session, he would text to tell them he wanted to reschedule the appointment.
The coroner asked if social media apps could also be a good way of communicating with young people, as these were free and did not rely on having phone credit.
Johnson said that was a good point and the service could look at setting up a profile with a provider such as WhatsApp.
Johnson said he had a good rapport with Liam.
“He was a nice guy, the sort that you remember.”
The health board’s psychiatric registrar who assessed Liam as having a low-to-moderate suicide risk on the night of September 14 at Christchurch Hospital gave evidence via video link. His name is suppressed at least until the coroner releases his findings.
The registrar, who was meeting Liam for the first time, said the risk assessment was based on a number of factors. These included that Liam had himself called for help, and, at the hospital, he was voicing a change in how he was feeling while acknowledging the suicidal thoughts he had earlier.
The registrar also gave his reasoning for not sectioning Liam for compulsory care under the Mental Health Act.
“I was concerned that would increase his sense of helplessness and having a lack of control over the situation, when he had ultimately sought help that night,” the registrar said.
He was also concerned the mental health hospital environment that Liam would be sectioned into would be “uncomfortable.” There were other consumers on the ward, including many suffering psychosis, and it could feel unsafe at times.
The coroner said it appeared incidents in the past where Liam had suicidal ideation were not on the suicide risk information sheet before the registrar on that night, and there had not been time for the registrar to go through all the progress notes. Hesketh also noted the registrar did not have access to Liam’s GP practice’s medical notes. He asked the registrar about the possibility of an “easy go-to document” that would give a clearer picture of worsening symptoms over time.
“If there’s better ways to summarise that information to really show key points, it might be something that’s useful,” the registrar said.
The health board’s psychiatric supervisor that the registrar had consulted with, by phone, on the night also gave evidence. Her name is also suppressed. The supervisor, who had never met Liam, said she and the registrar felt there would have been a high likelihood Liam would be discharged from hospital the next day if he was committed for compulsory care. Therefore, they would not achieve anything meaningful for him and he would be put off seeking further help.
“Alternatively it might have meant he got the shake up he needed, to essentially not behave the way he had, because you would have put him into hospital,” the coroner suggested.
The supervisor said Liam was discharged as an outpatient from the crisis resolution team’s care on September 29. She acknowledged Liam had a good relationship with a team social worker, but she believed the social worker would have told Liam that if he was not going well he could contact them again. The team members believed counselling through the alcohol and drug service worked well in engaging young people and this was the most effective path for Liam at that time.
CDHB chief of psychiatry Sigurd Schmidt gave evidence. He said there had been some health system changes since 2017.
These included texts being used more to communicate with patients, and auditing across CDHB services on how much families were part of discharge plans. However, family involvement when treating adult patients could be difficult due to privacy considerations.
In response to concerns about the registrar not being able to see notes from Liam’s GP to help guide him in his assessment, Schmidt said it had been acknowledged there could be one digital record which would follow through from primary to secondary care. There was already a digital platform, called HealthOne, which allowed access to information such as pharmaceutical records, but it did not allow access to GP notes. Creating such a digital record would be very costly, and privacy issues would have to be worked through.
“I think, with the new health reforms, there’s a hope there would be a single digital platform,” Schmidt said.
He said an existing digital platform for clinicians had a “traffic light system” that could be updated with the latest information on at-risk patients.
“A more fluid way would be helpful, where maybe the latest ones (incidents) are highlighted, but our current digital system is quite old,” Schmidt said.
The coroner wanted to know more about HealthOne and the traffic light system. He gave the CDHB’s counsel and police inquest officers the task of “homework” to find this information out for him. This was to help him in his findings, likely to be released in a few months time.
“It’s been a very intense two days,” Hesketh said in wrapping up the inquest.
He told Booth, now sitting in the courtroom with the picture of Liam at his side, that he had taken on board his concerns about the lack of information flow, and was working on everything he could to make it better.
Booth looked him in the eyes, and nodded.
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