Nurse expected colleagues to check Shaun Gray’s condition, inquest finds


A nurse responsible for the care of a patient at Palmerston North Mental Health Service who died in a suspected suicide did not check on him for an hour before he responded.

Shaun Gray passed away on April 16, 2014.
Photo: Provided

Shaun Gray died on April 16, 2014, after being admitted to the department’s high needs unit earlier that afternoon. He was supposed to be watched closely.

An inquest into his death in Palmerston North on Tuesday heard from the nurse overseeing the 30-year-old’s care this afternoon and evening.

The nurse, whose name is withheld, is not appearing as a witness, but her statements and answers to lawyers’ questions have been read.

The decision to excuse the nurse’s appearance was behind the Gray family’s decision not to take an active role in the investigation, although family members are watching from the public gallery.

Gray was admitted to the unit after being rushed to the hospital emergency department following an overdose the previous day. He admitted to having had suicidal thoughts.

The nurse, who at this point was inexperienced, said her behavior was aggressive throughout the afternoon of April 16, and that it was compounded by problems with her prescription medication.

Gray refused to take his nighttime medication and had a heated phone call with his father.

Towards the end of a “hectic” shift, the nurse observed him asleep on the mattress on the floor of his bedroom at 10 p.m.

After seeing his aggression during his phone call, the nurse said she was too terrified to watch him closely.

A few minutes later, the nurse asked her colleagues if she could leave the high needs unit to take notes for the shift. They said everything was fine, repeating that when she returned to the unit to check, she said.

Responding to questions from lawyers representing other workers on the ward, the nurse said she understood that when she or others went off to write notes, other staff were monitoring their patients.

When asked if it was her responsibility to arrange care for her patients, the nurse agreed, saying she thought the colleague she had told about leaving would.

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“I didn’t think at any time while I was out of the room that the checks hadn’t happened.”

Gray was found unresponsive in his room around 11 p.m., having not been checked in for 10 p.m.

“I expected other nurses to watch him when I was not in the [high-needs unit]”said the nurse.

“I think it’s important to note the following: senior management was very aware that I was struggling with Mr. Gray the entire shift and, since they had so much experience, I expected that that they support me, a nurse relatively new to the acute mental health service field.

“Mr. Gray was my first very aggressive patient and I was told I was fine in [another nurse with name suppression] during my shift.”

The nurse said that although she was aware of Gray’s previous suicidal thoughts, a transfer from a nurse on an earlier shift led her to believe her risk had decreased.

In the afternoon, Gray was “already irritable and angry”.

In the unit, the nurse said three staff members would supervise six patients.

Gray faced additional frustration when a doctor decided that her prescribed daily dose of 0.625 mg of triazolam should be 0.0625 mg instead. Later this was adjusted to 0.25mg, but staff could not initially find the drug on the ward.

Coroner Matthew Bates

Coroner Matthew Bates overseeing the inquest.
Photo: RNZ/Jimmy Ellingham

Methadone dose for a patient “out of step” with New Zealand practice

At one point, Gray was prescribed doses of methadone in excess of three times the recommended upper limit.

A doctor, whose name is withheld, said that in early 2013 Gray was taking 390 milligrams of methadone daily along with other prescribed medications.

Methadone is used to help drug-dependent patients break free from addiction to other drugs, and 120 mg per day is considered the upper limit of what should be prescribed.

The high dose was prescribed by Dr. Sarz Maxwell, who left the MidCentral District Health Board in mid-2013 and returned to the United States.

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“The doses were higher than those usually prescribed in New Zealand,” said the doctor who testified.

“She had published newspaper articles to support her view, but this did not meet New Zealand guidelines.”

Increased medical risks were among the possible side effects of heavy methadone use, he said.

The inquest heard on Monday that Maxwell’s prescribing practices were of concern to senior MidCentral officials, and were among 43 issues Coroner Matthew Bates wanted to discuss during the two-week inquest.

The doctor said such high doses for clients were gradually reduced and Gray, who suffered from an opioid addiction, mostly coped with them, including during periods under supervision.

In early 2014, he was taking methadone 100mg a day, but the doctor increased that to 120mg and switched to another medication he had been prescribed.

Gray was moved from midazolam to triazolam to help with sleep disturbances.

The doctor said he was uncomfortable with the daily prescription of midazolam, saying it was more commonly used before medical procedures.

This movement was another that the coroner wanted to examine.

“I have no reason to believe that switching from midazolam to triazolam contributed to Shaun’s mood swing,” the doctor said.

On April 15, 2014, Gray went to the alcohol and other drug department at MidCentral, upset that a chemist wouldn’t give him a take-home dose of methadone.

The doctor said he found no mention of past suicide attempts in Gray’s medical notes.

When the doctor last saw him before April 15, at the end of March, he wrote that Gray was “doing well.”

They discussed allowing Gray to carry doses of methadone so he wouldn’t have to go to the pharmacy every day, but other staff members later decided he wouldn’t. wasn’t ready.

Gray’s behavior on April 15 and 16, including attempts to bite and scratch medical personnel, was irrelevant.

The doctor said he had never seen such a reaction after being denied take-out methadone and assumed something else was troubling Gray.

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Gray remembers being a “friendly guy”

Pharmacist Glen Caves dispensed Gray’s prescription drugs in early 2014, including methadone.

“My memory of Shaun was that he was a pretty nice guy. I don’t remember seeing him angry.”

Pharmacist Glen Caves

Pharmacist Glen Caves testifies at the inquest.
Photo: RNZ/Jimmy Ellingham

Caves, who has since retired, said Gray knew his statute of limitations rights.

Gray was taking a mix of medications for anxiety and sleep issues.

His daily triazolam dose of 0.625 mg was above the recommended limit of 0.25 mg, but addicts could often develop high levels of tolerance, Caves said.

On April 15, Caves refused to give Gray take-out methadone because there had been no instruction from MidCentral’s addiction staff.

He couldn’t remember the details of the situation, but said Gray was frustrated rather than angry.

The mental health service, deemed unsuitable, is being replaced.

The investigation is continuing.

Where to get help:

Need to talk? Call for free or text 1737 anytime to speak to a qualified adviser, 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 might be thinking about suicide or those who are worried about their family or friends.

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Rural Support Trust helpline: 0800 787 254

Health line: 0800 611 116

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OUTLine: 0800 688 5463 (6pm-9pm)

If it is an emergency and you think you or someone else is in danger, call 111.



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