{"id":465814,"date":"2026-06-07T19:38:09","date_gmt":"2026-06-07T19:38:09","guid":{"rendered":"https:\/\/www.newsbeep.com\/nz\/465814\/"},"modified":"2026-06-07T19:38:09","modified_gmt":"2026-06-07T19:38:09","slug":"preventable-death-coroner-finds-palmerston-north-hospital-failings-linked-to-death-of-erica-hume","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/nz\/465814\/","title":{"rendered":"Preventable death: Coroner finds Palmerston North Hospital failings linked to death of Erica Hume"},"content":{"rendered":"<p class=\"DjAaGJVL\" style=\"display:none\">\u201cWe loved Erica. She was a young, vibrant student with so much potential and all she needed was someone in Ward 21 to pay attention to her, and actually help her when she realised, no, her safe haven had turned into a horror story,\u201d Carey said.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The \u201ccurious country girl\u201d who grew up on a North Island kiwifruit orchard took her own life at age 21, after she was admitted to the mental health ward at <a href=\"https:\/\/www.nzherald.co.nz\/topic\/hospitals\/41\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/topic\/hospitals\/41\/\">Palmerston North Hospital.<\/a><\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The Humes have in recent years spoken publicly about what happened, not only in their search for answers but to ensure the narrative around their daughter was accurate.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cWe knew our daughter,\u201d Carey said.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cShe was fully functional, studying, achieving great grades, well presented, had got herself a part-time job. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cShe didn\u2019t meet the picture of someone supposedly with <a href=\"https:\/\/www.nzherald.co.nz\/nz\/woman-who-died-of-suspected-suicide-not-bad-enough-to-access-mental-health-services\/LLU3SQKMXMK47B4WB3D3IV5SWM\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/nz\/woman-who-died-of-suspected-suicide-not-bad-enough-to-access-mental-health-services\/LLU3SQKMXMK47B4WB3D3IV5SWM\/\">mental health issues and that was half of the battle<\/a>,\u201d Carey said of the family\u2019s pleas for help.<\/p>\n<p>Death was \u2018preventable\u2019<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Erica had been admitted to the ward on May 6, 2014.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The following day, a nurse\u2019s hunch about her fragile state turned out to be true, but a decision to check on her was minutes too late.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Erica was found in her room in the ward alive but unconscious, after she was seen returning from lunch in the dining room.<\/p>\n<p><img  alt=\"Erica Hume's family say her mental health journey started when she was in Year 12.  Photo \/ Hume family\" class=\"article-media__image responsively-lazy\" data-test-ui=\"article-media__image\"\/>Erica Hume&#8217;s family say her mental health journey started when she was in Year 12.  Photo \/ Hume family<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Resuscitation efforts began immediately by staff and then continued once an emergency team arrived, but Erica remained unconscious.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">She was moved to the intensive care unit but her condition deteriorated, and she died nine days later.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\"><a href=\"https:\/\/www.nzherald.co.nz\/nz\/nurse-tells-inquest-into-suspected-suicide-she-didnt-know-the-man-was-at-risk\/3A4MZIFGWTAGISVN4JJARUILTE\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/nz\/nurse-tells-inquest-into-suspected-suicide-she-didnt-know-the-man-was-at-risk\/3A4MZIFGWTAGISVN4JJARUILTE\/\">Coroner Matthew Bates<\/a> was critical of hospital management and staff for a series of failures linked to what happened.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">He said her death was preventable.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\"><a href=\"https:\/\/www.nzherald.co.nz\/topic\/health-nz-te-whatu-ora\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/topic\/health-nz-te-whatu-ora\/\">Health New Zealand<\/a> said in a statement to NZME that it accepted the coroner\u2019s findings and recommendations and was committed to ensuring it learned from what happened.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The national director of mental health and addiction services, Phil Grady, said HNZ extended its deepest condolences to Erica\u2019s wh\u0101nau. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cErica\u2019s death has had a profound and lasting impact on her loved ones, and we acknowledge that this pain continues,\u201d he said. <\/p>\n<p>Self-harm occurred day after admission<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The self-inflicted harm which led to Erica\u2019s death happened the day after she was admitted. She died in the early hours of the morning on May 16.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Carey said as macabre as it might sound, the delay was a \u201cgift\u201d because they had time to say their goodbyes, and time to start asking questions.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Erica\u2019s death happened a month after the death of her friend, <a href=\"https:\/\/www.nzherald.co.nz\/nz\/shaun-grays-death-at-palmerston-north-hospital-avoidable-and-preventable-coroner-finds\/TGDQKKP4G5H6PAFMK7TNWRLI5Q\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/nz\/shaun-grays-death-at-palmerston-north-hospital-avoidable-and-preventable-coroner-finds\/TGDQKKP4G5H6PAFMK7TNWRLI5Q\/\">30-year-old Shaun Gray<\/a>, in the same ward, which had a big impact on their \u201csympathetic and empathetic\u201d daughter, Carey said.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cAs horrible as it was, and as traumatic for us and her siblings, we had those 10 days because if she had died straight away, we might never have found out information they [staff] were not telling us.\u201d<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The family didn\u2019t know Erica\u2019s phone had been misplaced on admission and she was unable to call them.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">It was a point raised by the coroner. He said if Erica had had her mobile phone on May 6 and 7 she would have had a greater opportunity to reach out to her friends or parents for additional support. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">A coronial inquest into Gray\u2019s death raised multiple issues about the way the hospital handled his care, NZME reported in 2022.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates said the circumstances around Erica\u2019s death highlighted gaps in resourcing and failures around adhering to adequate policy and procedures in place at the time, but they were not properly followed.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">He said that had they been, it may have prevented Erica\u2019s death, or at least materially reduced the chances of it occurring.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates said the circumstances around Erica\u2019s death highlighted the limited nursing resources available to Ward 21 at the time, the absence of a cohesive team nursing approach, and a poorly designed ward that was \u201cnever fit for purpose\u201d.<\/p>\n<p><img  alt=\"Erica Hume pictured when she was about seven-and-a-half years old. Her mother, Carey Hume, described her as a &quot;typical Kiwi country girl&quot;, who had the confidence to give things a go.  Photo \/ Hume family\" class=\"article-media__image responsively-lazy\" data-test-ui=\"article-media__image\"\/>Erica Hume pictured when she was about seven-and-a-half years old. Her mother, Carey Hume, described her as a &#8220;typical Kiwi country girl&#8221;, who had the confidence to give things a go.  Photo \/ Hume family<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">He acknowledged that a new acute mental health facility at the hospital, Ng\u0101 Wai Ng\u0101ro, was now operational but said any lessons learned should be applied to the new unit. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Grady, on behalf of HNZ, said <a href=\"https:\/\/www.nzherald.co.nz\/topic\/mental-health\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/topic\/mental-health\/\">mental health inpatient services<\/a> were complex environments that provided care for people who were often highly unwell and in acute distress. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cWe recognise there is always more work to do to ensure we provide safe, high-quality care for patients and a safe working environment for staff,\u201d he said. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates found Erica intended to end her own life, but acknowledged her family\u2019s view that, ultimately, in a more general sense, she did not want to die.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">He also acknowledged that when she was admitted to Ward 21, she was actively seeking help from mental health services to try to live. <\/p>\n<p>Classified as \u2018high risk\u2019 <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">According to evidence heard at the 2022 inquest, in 2014 Erica called her care worker at <a href=\"https:\/\/www.nzherald.co.nz\/topic\/palmerston-north\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/topic\/palmerston-north\/\">Palmerston North<\/a> Mental Health Services and said she was having thoughts about harming herself.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The next day, she was admitted to Ward 21 on a voluntary basis. Her care worker filled out a risk assessment form, classifying her as \u201chigh risk\u201d.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">However, staff at the ward left her admission paperwork for the night shift to complete and no formal assessment of her risk was undertaken while she was in the ward\u2019s care.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Overnight, she was checked every half hour. The next day, she briefly left her room for lunch before returning.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">It was just before 1pm when she was found unconscious in her room.<\/p>\n<p>Mental health journey began years earlier<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Owen Hume told the inquest his daughter\u2019s mental health journey started years earlier when she was in Year 12 and told a teacher she \u201cwasn\u2019t doing too good\u201d.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">She was referred to the school counsellor who took Erica to a doctor who prescribed anti-psychotic medication. Meanwhile, she developed multiple eating disorders.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">All of this occurred without her parents\u2019 knowledge.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cI knew something wasn\u2019t right but as a mum of a teenage girl, you try to figure things out and not upset them. You nurture them through but it was the beginning of the end in that respect,\u201d Carey said.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">By the time they found out and the <a href=\"https:\/\/www.nzherald.co.nz\/topic\/bay-of-plenty\/\" target=\"_self\" rel=\"nofollow noopener\" title=\"https:\/\/www.nzherald.co.nz\/topic\/bay-of-plenty\/\">Bay of Plenty District Health Board<\/a> became involved, it was too late for her to access youth mental health services.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The Humes tried to get mental health support while Erica was attending Massey University in Palmerston North but she was deemed \u201cnot bad enough\u201d. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">It was recommended that she access the university\u2019s counselling services.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Massey quickly established that Erica\u2019s situation was too serious for them to deal with and referred her back to Palmerston North Mental Health Services.<\/p>\n<p>Contributing factors <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates found several contributing factors linked to Erica\u2019s death, including her mental state at the time, plus failure by Ward 21 staff to complete a risk assessment form upon Erica\u2019s admission.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Ward staff also failed to carry out observations in accordance with MidCentral District Health Board (MCDHB) policy and procedure.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The actions which led to her death \u201cdemonstrated a degree of premeditation and planning to end her life\u201d, Coroner Bates said in the findings.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cHer intent crystallised after she learned that Mr Gray had ended his life.\u201d<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cNo one checked on Erica for a critical 55-minute period on the morning of May 7, 2014, during which the nurse allocated to Erica\u2019s care was absent from the open side of Ward 21.\u201d<\/p>\n<p><img  alt=\"Palmerston North Hospital's new mental health unit, Ng\u0101 Wai Ngaro, opened in February 2026. Photo \/ Semtex Plumbing &amp; Civil\" class=\"article-media__image responsively-lazy\" data-test-ui=\"article-media__image\"\/>Palmerston North Hospital&#8217;s new mental health unit, Ng\u0101 Wai Ngaro, opened in February 2026. Photo \/ Semtex Plumbing &amp; Civil<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates said if a psychiatric assessment had taken place following her admission to the ward, it may have alerted nursing staff to her heightened risk of suicide by the method she chose. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">However, Coroner Bates accepted it was not always possible for assessment to occur immediately after admission, particularly if it was later in the day or during the evening after the ward psychiatrists had left. <\/p>\n<p>Ward operating \u2018at or over capacity\u2019<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">The consultant psychiatrist on Ward 21 intended to assess Erica as soon as possible the day after she was admitted but couldn\u2019t because of high demands on the ward that morning, and the need to prioritise other \u201covertly\u201d acutely unwell patients, the coroner said.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cThis highlights the fact that Ward 21 was often operating at or over capacity, with high acuity, and with limited staffing resources,\u201d he said. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Recommendations made by the coroner included that admission documents should be completed at the point of admission and that psychiatric assessment of newly admitted patients should occur as soon as possible.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">There was also a need for clearer protocols for staff to easily identify observation levels in place for each patient, plus the introduction of training audit systems to monitor whether staff were meeting training requirements. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Health New Zealand MidCentral said significant progress had already been made in implementing many of the recommendations. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Grady said in the 12 years since Erica\u2019s death, significant changes had been made across mental health services, including the move to the new purpose-built acute mental health unit, which opened in February.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cOur model of care has also evolved. Since Erica\u2019s death, we have seen the introduction of a shared electronic patient record across community and inpatient services. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cThis has strengthened clinical handovers and improved visibility of patient information, supporting more timely and informed decision-making,\u201d Grady said. <\/p>\n<p>Relief for family<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Coroner Bates hoped the conclusion of the inquiry would bring some relief to all those affected by Erica\u2019s death, in particular her family. <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Carey said it was less a closure than a beginning.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cFor us, it\u2019s about the hospital management and staff having to start having accountability now.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cI say that because our experience over the past 12 years is that no changes last. You\u2019re lucky if they last 12 months before they\u2019re either ignored or dropped altogether.<\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">\u201cBut you\u2019ve got to hope there\u2019s change and reports aren\u2019t put in the bottom drawer and forgotten about.\u201d <\/p>\n<p class=\"DjAaGJVL\" style=\"display:none\">Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ\u2019s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail. <\/p>\n","protected":false},"excerpt":{"rendered":"\u201cWe loved Erica. She was a young, vibrant student with so much potential and all she needed was&hellip;\n","protected":false},"author":2,"featured_media":465815,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[12629,868,634,8912,5031,23944,11424,2241,235934,7055,111,43,139,529,69,1118,6292,384,79703,544,427,8911,1961,61,1455,102],"class_list":["post-465814","post","type-post","status-publish","format-standard","has-post-thumbnail","category-new-zealand","tag-coroner","tag-deals","tag-death","tag-distressing","tag-erica","tag-failings","tag-finds","tag-hospital","tag-hume","tag-linked","tag-new-zealand","tag-news","tag-newzealand","tag-north","tag-nz","tag-of","tag-palmerston","tag-people","tag-preventable","tag-some","tag-story","tag-suicide","tag-this","tag-to","tag-warning","tag-with"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/465814","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=465814"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/465814\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/465815"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=465814"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=465814"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=465814"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}