Warning: This story contains details that some readers may find distressing
A year after the death of a man who fell or jumped out a Palmerston North Hospital window, his family are still waiting to see someone take responsibility.
Paul Rowe lay injured for more than two hours until he was found on a balcony two storeys below the ward he was in.
Despite coming to hospital with a self-inflicted wound he was never assessed by a mental health team.
Still grieving his death, which happened on 14 June last year, Rowe's sister and family spokeswoman, Lisa Stevenson, can't accept her brother is gone.
Nor can she believe that a hospital investigation - the final draft of a "serious adverse event review" report - into what happened identified no direct factors behind the 58-year-old's death.
"There're security failures. There're mental health assessment failures. There's input in regards to the level of care Paul should be put under," Stevenson said.
"There're so many factors that have resulted in his death that [the hospital is] not taking responsibility for, so that's frustrating our family a lot."
Rowe was admitted to Palmerston North Hospital on 6 June last year.
In the early hours of 8 June he went missing from a ward where he was recovering from repair work to his wound.
Despite lying injured on a balcony two storeys below the window above his bed, he wasn't found for about two-and-a-half hours.
The window would only open a small distance and the balcony below wasn't used at the hour of the day Rowe disappeared, so it was assumed he wasn't there.
Initially when staff looked out the window they couldn't see him lying below, because a ledge obstructed the view, but when police were called an officer spotted him.
Rowe died of his injuries in Wellington Hospital on 14 June.
Stevenson said now the hospital investigation was complete the family would complain to the health and disability commissioner.
She felt the family's suggested improvements were ignored by health officials.
"We just feel completely dismissed by the hospital. To get the final [report] draft and basically be told this is the end of the road for us, and if you want to pursue any further information or anything else you've got to lodge a complaint.
"It feels like we're back to square one and we're not being heard."
Rowe's death is also the subject of a coronial inquiry.
Stevenson said she would likely represent the family if an inquest were held because they couldn't afford a lawyer and probably weren't eligible for legal aid.
"It's most definitely not an even playing field. The hospital gets all the support and the legal aid and the legal help to basically try and not take any responsibility for a patient's death."
Another problem with Rowe's care was that when he was missing from the ward, security staff thought they'd found him outside. But the man they identified wasn't him, and no identity check was made.
Rowe's family have said this would have eaten into valuable time as he lay injured and undiscovered.
The hospital report makes several recommendations, including improvements to mental health assessment and search procedures.
DHB accepts findings
MidCentral District Health Board acute and elective specialist services operations executive Lyn Horgan said the report findings were accepted.
"MidCentral DHB extends our sympathies to Mr Rowe's whānau and friends and are conscious of the grief they have endured given the time since his death. The final draft of the event review report has now been presented to them," she said.
"We know that parts of our mental health service did not deliver as they should have, and we apologise to the family for this.
"In particular, we acknowledge that Mr Rowe should have promptly had a mental health assessment. That said, MidCentral agrees with the report that there were no causal factors that resulted in Mr Rowe's death."
It was expected Rowe would move into the hospital's mental health ward for further care.
Officials accept the ward is not fit for purpose and a new one is due to open later next year, a year later than planned.
Horgan said the report's recommendations would be implemented by 30 August, including retraining security staff, providing them with better information about missing patients, and reviewing procedures so searches included places not usually checked.
New best practice standards would be introduced so patients who arrive at hospital, but not at the mental health ward, had a mental health assessment as soon as possible.
"Our analyst team found that even if our processes had been improved, it is unlikely that they would have been able to prevent Mr Rowe's death.
"If security or staff had found Mr Rowe earlier, it unfortunately would not have been enough to change the outcome, as his injuries were significant and medical staff indicate that the time delay was not a factor in his passing."
Stevenson and her family don't accept this.
After a year, they were still learning to cope with Rowe's death, and felt exhausted.
"It's a daily struggle, I'll be honest...
"There's since been one other death at the hospital we know of in relation to mental health issues.
"We want to stop these unnecessary deaths, but nothing's going to bring back our brother, father and poppy Paul."
Stevenson said she and her family would keep advocating for change.
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 (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) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. 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 (6pm-9pm)
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