“The services suffer from persistent underfunding, resulting in inpatient services that are less than half what might be expected in similar western jurisdictions.”
Keil was found dead in the garden belt surrounding the Tiaho Mai mental health unit, 5 metres from the window through which he is believed to have escaped on February 7 2022. He was found by his mum, Debbie Thorpe, 16 hours later.
Jordan Keil’s mum (left) stands next to his dad, Mike Keil, outside the Auckland District Court awaiting the first day of the inquest into his 2022 death. Mike Keil holds their son’s ashes. Jordan Keil is pictured in the framed portrait. Photo / Michael Craig
Coroner Rachael Schmidt-McCleave has heard testimony of failures in care leading up to Keil’s escape, including key staff being unaware of two suspected suicide attempts prior to his admission.
Keil was committed for treatment under the Mental Health Act after weeks of increasing anxiety and paranoia – a situation that confused and distressed family and friends with whom he had spent a loving Christmas and summer holiday.
He had been in Taiho Mai for a week at the point he escaped with uncertainty over when he was last seen despite staff mandated to check on him every 15 minutes.
McMinn, who works as a forensic psychiatrist for Health NZ, was an expert witness and among the last to testify in this phase of the inquest into Keil’s death in 2022. He was also a deputy psychiatrist member of the Mental Health Review Tribunal and sits on a range of professional bodies.
He presented to the inquest research showing similar Western nations funded inpatient mental health care at 71-93 beds per 100,000 people but New Zealand funded it at 31-38 beds for the same population.
“In this context, it is inevitable that patients need to be shuffled through the system as quickly as possible, in an attempt to allow for service to still remain available to those in need of admission or emergency care.
“It should also be no surprise that the staff are constantly occupied across stretched demands and face trying to make the best decision in the context of multiple hazards.”
Family and friends of Jordan Keil at the Auckland District Court for the inquest into his death in 2022. His father, Mike Keil, leads the group holding the ashes of his son. Photo / Michael Craig
McMinn said this situation was exacerbated during the period in which Keil was being treated in a mental health system with no capacity for new patients and reeling from constant changes to Covid-19 mitigation strategies.
He said it would have been challenging enough but there was “no slack in the system” and not enough time to keep pace with constant changes and tend to the needs of patients.
McMinn said a 2021 survey found 94% of doctors working in psychiatry believed there was insufficient funding. He also provided a 2022 paper highlighting a “mental health crisis”, saying there were now more vacancies for psychiatrists yet fewer people training in the speciality.
McMinn said a review he had been provided showed “many of the individual apparent shortfalls” in Keil’s care that “might contribute to better practice in the future”. He said that would be the case if staff knew of and followed changes to multiple policies.
But he said, “The changes rely on the system as it is working better.
“They do little to enhance the working of a system that is multiply under strain through being under-resourced for which there has been years of warning to little heed.”
Northern region clinical director of mental health and addictions Dr Ian Soosay said Keil’s transport from Auckland Hospital to Tiaho Mai in a car with two nurses in the front seat and no one in the back was “less than ideal”.
It was on that journey Keil – 185cm and weighing more than 90kg – climbed out an open window on the Southern Motorway before spending eight hours atop the Sylvia Park mall car park threatening to jump.
But Soosay said it was in keeping with the move towards “least restrictive” handling of mental health patients which was intended to have better clinical outcomes. He said handcuffing patients, as police had done in the past, could have adverse effects.
Jordan Keil, 25, who died in February 2022.
He acknowledged the incident at Sylvia Park, and an earlier incident the same day, were among information missing from files at Tiaho Mai because the “living document” that tracked a patient’s care had suffered from cutting-and-pasting.
Soosay sought to provide contrast between the way Tiaho Mai operated when “functioning outside of a pandemic”. He said he was concerned to see comments from Thorpe and Keil’s dad, Mike Keil, suggesting Tiaho Mai was unsafe for young people.
He said it “generally provides safe care that is beneficial to some of the most mentally ill people in our population”.
But in February 2022, he said preparations for the new strain of Covid-19 “may have contributed to Jordan’s ability to escape the unit and ultimately lose his life”.
He said “hurried arrangements” to prepare for the new Omicron variant led to a failure to consider properly the differences between high-dependency units, in which Keil had been kept for most of his stay, and the less secure unit from which he escaped.
Soosay said it was not known at the time that Omicron was less deadly and preparations were being made for an “anticipated surge” in cases.
He said it created a “Swiss cheese” alignment of an “unprecedented number of errors” – something he said he accepted “and deeply regretted)”.
Soosay said an initial month-long silence from the hospital to Keil’s whanau after the young man’s death was due to the hospital’s mistaken belief they did not want contact. He said he was “mortified” when he discovered this misunderstanding – “This was a mistake on our part and I’m truly sorry.”
However, he said there had since been genuine efforts to be upfront with Keil’s whanau with internal and external reviews carried out and shared, and genuine efforts to find people with whom they could connect, along with apologies given.
At the start of Soosay’s testimony, he offered another, saying he was “truly sorry, personally sorry”, and “on behalf of the service”, saying the inquest had highlighted failures and aspersions – “particularly issues around drug use” – that “have trampled on the mana of Jordan”.
One issue contested by Keil’s family were medical notes that suggested binge drinking and daily use of MDMA, which they had said was inaccurate. Keil’s mother has testified being told by his friends that he had used MDMA on three occasions.
The inquest also heard evidence that there was no physical search for Keil outside Tiaho Mai once he was known to be missing.
David Fisher is a senior journalist for the New Zealand Herald who has twice been named New Zealand’s Reporter of the Year. David is based in Northland and has worked as a journalist for more than 30 years, winning multiple journalism awards and being selected as one of a small number of Wolfson Press Fellows to Wolfson College, Cambridge. He joined the Herald in 2004.
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