He had attempted suicide twice and had been admitted to secure facilities.
His death was referred to Coroner Tracey Fitzgibbon.
His mother Kelly Logan hoped the coroner would take an in-depth look at what had happened and determine if anything could have changed the tragic trajectory of her son’s last day.
She asked the coroner to look at the phone calls she and her son made the day he died – saying they had both been calling Kessels’ mental health team trying to get help – and the responses they received.
But Coroner Fitzgibbon decided an inquest was not necessary, saying she had the information she needed to determine Kessels’ cause of death.
She released her findings in February, confirming that based on information provided to her, including from police and Te Whatu Ora, Kessels’ death was a suicide.
But the report did not address Logan’s concerns that calls for help had gone unanswered, nor did it canvas whether anything could have been done to prevent his death.
Sean Kessels’ family are traumatised by his death. Photo / Supplied
A “team learning review” was also carried out by Te Whatu Ora Health New Zealand.
Its findings said “due diligence has been completed” and there were no “conspicuous oversights”, with follow-up actions considered appropriate to Kessels’ clinical needs and interactions with Kessels and his family deemed appropriate. It also stated there were “no early warning signs” before he died.
The review did not mention any calls for help from Kessels or his mother in the days leading up to his death. Te Whatu Ora said the issue of communications would be investigated further through the wider learning review, and acknowledged it “could have done more to engage with Sean’s family”.
Logan was unimpressed by the findings, saying the review was “disgustingly false and inaccurate” and did not properly address what happened to her son.
On June 3, 2025, Logan and her daughter met with Simon Judkins, the clinical head of adult community mental health services for Counties Manukau, and Middlemore Hospital’s mental health and addictions quality and risk manager Denis Smith.
They confirmed a Serious Incident Learning Review of Kessels’ death was underway.
“They promised me that the review would be a priority and they would work to get everything done within a few months,” Logan said.
“The last time I heard anything was on the 8th of July from Denis saying they had met with people involved and hoped to have it to me within six to eight weeks.”
Logan said she heard “absolutely nothing” after that.
Sean Kessels and his mum Kelly Logan. Photo / Supplied
In early 2026, she sent an email to the pair and Judkins told her Smith had been off sick.
There was no further contact from anyone at Te Whatu Ora until July – after the Herald sought answers about the review on June 17.
On June 19, Logan said Judkins called her with “apologies and excuses” and promised the draft review would be available within a week. He invited her to meet with him in early July to discuss it.
Logan declined the meeting, and the review was finally sent to her by email on July 13.
She was appalled by the contents and said there was still “lots of wrong information” in the document.
She was also devastated as she and three family members provided deeply personal letters about Kessels’ life and death to Judkins. Only one was used in the review – from Kessels’ sister – which Logan said was insulting and hurtful.
The review noted that Kessels’ family had been “shocked and further distressed” by the first review.
“Partly as a result of this, the decision was made to undertake a wider investigation, to hear more of the whaanau perspective, and for the service involved to have an opportunity to reflect upon the sad loss of this young man,” it said.
It said the second review was completed to “prioritise whānau voice, which is not apparent in clinical records, and contributes greatly to sensemaking”.
“We would like to extend our sincere condolences to Mr Kessels’ whānau and apologise for the delays in providing this written review and for the additional distress this has caused,” it stated.
“Kelly (Sean’s mother) and Courtney (his sister) described a prolonged period in which they actively sought care and support for Sean as his mental health deteriorated. Their central concern was that, during a clear relapse characterised by paranoia, behavioural change, distress and suicidality, Sean was not admitted … for comprehensive assessment and treatment. They believe that inpatient care at that time would have enabled appropriate medication review and stabilisation, potentially altering the course of events.”
Sean Kessels loved his family – but kept much of his mental health struggle from them. Photo / Supplied
The second review acknowledged that Kessels’ family had consistently described significant difficulty accessing timely, responsive and coordinated care, particularly in the months leading up to his death.
“They reported limited responsiveness from services, difficulty contacting the assigned mental health clinician, a lack of proactive engagement and follow-up [and] care that appeared focused primarily on medication provision rather than holistic,” the report said.
“The whānau raised serious concerns about crisis service responsiveness, reporting multiple instances where calls for help were not answered, not followed up, or were perceived as dismissive. They described situations in which Sean was left distressed and unsupported despite clear expressions of suicidality.
“They described feeling that they had to persistently advocate for Sean, often without feeling heard or supported, and reported a lack of communication and partnership with services. They noted that no formal support was offered to the whanau themselves, despite the significant impact of Sean’s mental health concerns.”
The review also found the family and treating team had different understandings of Kessels’ clinical presentation leading up to his death.
Logan believed her son was experiencing a recurrence of psychosis and there were many red flags including aggression, worsening distress and suicidality.
The review stated that his treating team “conceptualised this differently’ and his family felt that “contributed to missed opportunities for escalation and more intensive intervention”.
“More broadly, the family expressed a profound sense that Sean’s level of need exceeded the care that was able to be provided, particularly during a period of marked change in behaviour and increased risk,” it said.
“They found it difficult to understand how significant warning signs – including new aggression, worsening distress, and suicidality – did not lead to more assertive intervention such as an acute admission … The family also spoke of the care he received as being primarily crisis-driven, rather than proactive and recovery-focused.
“Overall, the whānau perspective is that systemic limitations in access, responsiveness, communication and coordination contributed to Sean not receiving the level of care required, and that earlier, more assertive and compassionate intervention may have changed the outcome.”
The review was promised last year but did not get sent to Sean’s family until after the Herald sought answers. Photo / NZME
The review said Kessels’ sudden death came as a “shock and a surprise” to his mental health team.
“In reviewing the care that was provided and speaking to Sean’s family, it is clear that whilst there were good aspects to the care he received, there were significant difficulties,” it read.
“There were significant risks due to the speed with which Sean could relapse, and he could act impulsively, and he sometimes was very influenced by the strength of his delusional beliefs.”
The report acknowledged that Kessels’ family felt he should have been admitted to an acute psychiatric unit, given his “struggles with a fluctuating mental state” in 2023.
“The team reflected on this and indicated that it can be very difficult to determine the best balance of approach over the course of treatment,” the report said.
“They aim to provide recovery-focused care in the least restrictive way, and so … there is a tendency to prefer community-based care when risks can be managed.
“The team recognises that acute hospital admissions are often experienced as distressing and at times traumatic … There is also no doubt that there is a limited supply of inpatient beds in the region.
“Overall, it was the general opinion that the decision not to admit Sean in January 2023 was a reasonable course of action based on their assessment of his needs at the time. However, the team acknowledges that the family are left feeling that more could have been done.”
The report also acknowledged that for Kessels’ family, supporting him through his illness was “extremely stressful” and no referrals to appropriate organisations were made for them for “support and advice”.
“This may have been helpful in supporting the family to navigate a complicated mental health system and support a young man with complex mental health needs,” the report concluded.
“We acknowledge we should have done more to support you as a family ourselves.”
Sean and his sister Courtney. Photo / Supplied
The review identified a number of changes Te Whatu Ora said had been made since Kessels’ death, including better co-ordination between acute and community teams.
Te Whatu Ora also acknowledged the delay in completing the review, saying such situations “create an unacceptable additional stressor on the bereaved families following an already tragic and distressing event”.
“In this case, the delays have been unacceptably long, and we apologise to Sean’s family for this,” the agency said.
Logan said the final review was “ridiculous” and “just another kick in the teeth”.
“For example, it said Sean’s team was ‘shocked’ he died – I was telling them for months that would happen,” she said.
“This was a complete waste of time, it’s utter bulls***.
“It just feels like Sean didn’t matter to them, that he wasn’t important. It felt like they rushed it through.”
Logan said her dealings with health authorities had left her “disillusioned”.
She had been considering further action but had decided to stop fighting.
“I’m going to leave it, but I think it just needs to be said how bad it is,” she said.
“I want to get it across that the review was really bad. I want [Te Whatu Ora] to know it is just ridiculous and I am done.”
In a statement, Vanessa Thornton, the organisation’s group director for operations in Counties Manukau, acknowledged “the ongoing grief” Kessels’ family was experiencing and the “profound impact his death continues to have”.
“We would also like to apologise for the delays in providing the review to them and the additional stress this has caused,” she said.
“The completion of the learning review was delayed due to the staff member undertaking the review leaving their role suddenly, due to an unrelated reason, slowing its completion.”
Thornton reiterated that the review sought to “understand the circumstances surrounding Sean’s death and identify opportunities to learn from and strengthen clinical and organisational systems”.
“We have made a number of changes to how the Counties Manukau Adult Mental Health Service operates following Sean’s death.”
She said changes included “improved suicide prevention training for staff”.
“We have met with Sean’s family and are more than happy to meet with them again to discuss the review,” she said.
“We remain committed to learning from Sean’s death, listening to his loved ones, and improving based on their experiences, while continuing to improve the care and support we provide to people accessing our mental health services.”
‘I feel like a massive failure’: A sister’s grief
Leading up to the review, Kessels’ mother, sister and two other family members provided letters about his life and the impact his death had on them.
Just one was included in the official, complete review, written by his sister Courtney.
It read: “Sean was my brother. A human being who unfortunately got struck with a s*** deck of cards in life. We had the same childhood, the same trauma, the same home life and the same parents. It doesn’t seem fair that he got a life of pain and struggle and I didn’t. And that’s something that as a sibling will never go away.
“When I read the review on Sean’s report, I couldn’t believe the words on the paper in front of me.
“My heart, that’s already shattered, tore a little more for my brother. I always knew the system was bad, but to read that … was a painful moment of my life I’ll never forget.
Sean and his sister Courtney were very close. Photo / Supplied
“When we were younger, I left home quite early and was independent. Had my son at 21 and moved to a different suburb. Just normal life things that people do when they grow up, but Sean didn’t. He didn’t grow up, leave and have children.
“He was stuck in a world that as a young mum I didn’t understand. I knew he was sick, but naively I thought he’d have a good support team to guide him through this life.
“It breaks my heart that I was wrong and I wasn’t there for him more. Something I have to live with every single day; I feel like a massive failure to my brother.
“Sean was many things to those who knew him. He was quiet but observant, he was tall but gentle, he was big but cuddly. He was so intelligent that he would blow you away with his knowledge. He was quirky and took interest in things a lot of other people don’t.
“He was an uncle to my children and my niece. He was our brother. He was a son. He was a nephew and a grandson. Most importantly, he was loved by so many, and he didn’t even know how much because of this s*** illness.”
Anna Leask is a senior journalist who covers Christchurch issues and national crime and justice. She joined the Herald in 2008 and has worked as a journalist for more than 20 years with a particular focus on family and gender-based violence, child abuse, sexual violence and homicides. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz.
A Moment in Crime is a NZ Herald podcast.