But the report did not address Logan\u2019s concerns that calls for help had gone unanswered, nor did it canvas whether anything could have been done to prevent his death.<\/p>\n
Sean Kessels’ family are traumatised by his death. Photo \/ Supplied<\/p>\n
A \u201cteam learning review\u201d was also carried out by Te Whatu Ora Health New Zealand.<\/p>\n
Its findings said \u201cdue diligence has been completed\u201d and there were no \u201cconspicuous oversights\u201d, with follow-up actions considered appropriate to Kessels\u2019 clinical needs and interactions with Kessels and his family deemed appropriate. It also stated there were \u201cno early warning signs\u201d before he died.<\/p>\n
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 \u201ccould have done more to engage with Sean\u2019s family\u201d.<\/p>\n
Logan was unimpressed by the findings, saying the review was \u201cdisgustingly false and inaccurate\u201d and did not properly address what happened to her son. <\/p>\n
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\u2019s mental health and addictions quality and risk manager Denis Smith. <\/p>\n
They confirmed a Serious Incident Learning Review of Kessels\u2019 death was underway. <\/p>\n
\u201cThey promised me that the review would be a priority and they would work to get everything done within a few months,\u201d Logan said.<\/p>\n
\u201cThe 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.\u201d<\/p>\n
Logan said she heard \u201cabsolutely nothing\u201d after that. <\/p>\n
Sean Kessels and his mum Kelly Logan. Photo \/ Supplied<\/p>\n
In early 2026, she sent an email to the pair and Judkins told her Smith had been off sick.<\/p>\n
There was no further contact from anyone at Te Whatu Ora until July \u2013 after the Herald sought answers about the review on June 17. <\/p>\n
On June 19, Logan said Judkins called her with \u201capologies and excuses\u201d and promised the draft review would be available within a week. He invited her to meet with him in early July to discuss it. <\/p>\n
Logan declined the meeting, and the review was finally sent to her by email on July 13. <\/p>\n
She was appalled by the contents and said there was still \u201clots of wrong information\u201d in the document.<\/p>\n
She was also devastated as she and three family members provided deeply personal letters about Kessels\u2019 life and death to Judkins. Only one was used in the review \u2013 from Kessels\u2019 sister \u2013 which Logan said was insulting and hurtful. <\/p>\n
The review noted that Kessels\u2019 family had been \u201cshocked and further distressed\u201d by the first review.<\/p>\n
\u201cPartly 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,\u201d it said. <\/p>\n
It said the second review was completed to \u201cprioritise wh\u0101nau voice, which is not apparent in clinical records, and contributes greatly to sensemaking\u201d.<\/p>\n
\u201cWe would like to extend our sincere condolences to Mr Kessels\u2019 wh\u0101nau and apologise for the delays in providing this written review and for the additional distress this has caused,\u201d it stated. <\/p>\n
\u201cKelly (Sean\u2019s 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 \u2026 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.\u201d<\/p>\n
Sean Kessels loved his family \u2013 but kept much of his mental health struggle from them. Photo \/ Supplied<\/p>\n
The second review acknowledged that Kessels\u2019 family had consistently described significant difficulty accessing timely, responsive and coordinated care, particularly in the months leading up to his death.<\/p>\n
\u201cThey 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,\u201d the report said. <\/p>\n
\u201cThe wh\u0101nau 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. <\/p>\n
\u201cThey 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\u2019s mental health concerns.\u201d<\/p>\n
The review also found the family and treating team had different understandings of Kessels\u2019 clinical presentation leading up to his death.<\/p>\n
Logan believed her son was experiencing a recurrence of psychosis and there were many red flags including aggression, worsening distress and suicidality.<\/p>\n
The review stated that his treating team \u201cconceptualised this differently\u2019 and his family felt that \u201ccontributed to missed opportunities for escalation and more intensive intervention\u201d.<\/p>\n
\u201cMore broadly, the family expressed a profound sense that Sean\u2019s level of need exceeded the care that was able to be provided, particularly during a period of marked change in behaviour and increased risk,\u201d it said. <\/p>\n
\u201cThey found it difficult to understand how significant warning signs \u2013 including new aggression, worsening distress, and suicidality \u2013 did not lead to more assertive intervention such as an acute admission \u2026 The family also spoke of the care he received as being primarily crisis-driven, rather than proactive and recovery-focused.<\/p>\n
\u201cOverall, the wh\u0101nau 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.\u201d<\/p>\n
The review was promised last year but did not get sent to Sean’s family until after the Herald sought answers. Photo \/ NZME<\/p>\n
The review said Kessels\u2019 sudden death came as a \u201cshock and a surprise\u201d to his mental health team.<\/p>\n
\u201cIn reviewing the care that was provided and speaking to Sean\u2019s family, it is clear that whilst there were good aspects to the care he received, there were significant difficulties,\u201d it read.<\/p>\n
\u201cThere 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.\u201d<\/p>\n
The report acknowledged that Kessels\u2019 family felt he should have been admitted to an acute psychiatric unit, given his \u201cstruggles with a fluctuating mental state\u201d in 2023. <\/p>\n
\u201cThe team reflected on this and indicated that it can be very difficult to determine the best balance of approach over the course of treatment,\u201d the report said.<\/p>\n
\u201cThey aim to provide recovery-focused care in the least restrictive way, and so \u2026 there is a tendency to prefer community-based care when risks can be managed. <\/p>\n
\u201cThe team recognises that acute hospital admissions are often experienced as distressing and at times traumatic \u2026 There is also no doubt that there is a limited supply of inpatient beds in the region. <\/p>\n
\u201cOverall, 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.\u201d<\/p>\n
The report also acknowledged that for Kessels\u2019 family, supporting him through his illness was \u201cextremely stressful\u201d and no referrals to appropriate organisations were made for them for \u201csupport and advice\u201d.<\/p>\n
\u201cThis 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,\u201d the report concluded. <\/p>\n
\u201cWe acknowledge we should have done more to support you as a family ourselves.\u201d<\/p>\n
Sean and his sister Courtney. Photo \/ Supplied<\/p>\n
The review identified a number of changes Te Whatu Ora said had been made since Kessels\u2019 death, including better co-ordination between acute and community teams.<\/p>\n
Te Whatu Ora also acknowledged the delay in completing the review, saying such situations \u201ccreate an unacceptable additional stressor on the bereaved families following an already tragic and distressing event\u201d.<\/p>\n
\u201cIn this case, the delays have been unacceptably long, and we apologise to Sean\u2019s family for this,\u201d the agency said. <\/p>\n
Logan said the final review was \u201cridiculous\u201d and \u201cjust another kick in the teeth\u201d.<\/p>\n
\u201cFor example, it said Sean\u2019s team was \u2018shocked\u2019 he died \u2013 I was telling them for months that would happen,\u201d she said.<\/p>\n
\u201cThis was a complete waste of time, it\u2019s utter bulls***.<\/p>\n
\u201cIt just feels like Sean didn\u2019t matter to them, that he wasn\u2019t important. It felt like they rushed it through.\u201d<\/p>\n
Logan said her dealings with health authorities had left her \u201cdisillusioned\u201d.<\/p>\n
She had been considering further action but had decided to stop fighting.<\/p>\n
\u201cI\u2019m going to leave it, but I think it just needs to be said how bad it is,\u201d she said.<\/p>\n
\u201cI 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.\u201d<\/p>\n
In a statement, Vanessa Thornton, the organisation\u2019s group director for operations in Counties Manukau, acknowledged \u201cthe ongoing grief\u201d Kessels\u2019 family was experiencing and the \u201cprofound impact his death continues to have\u201d.<\/p>\n
\u201cWe would also like to apologise for the delays in providing the review to them and the additional stress this has caused,\u201d she said.<\/p>\n
\u201cThe 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.\u201d<\/p>\n
Thornton reiterated that the review sought to \u201cunderstand the circumstances surrounding Sean\u2019s death and identify opportunities to learn from and strengthen clinical and organisational systems\u201d.<\/p>\n
\u201cWe have made a number of changes to how the Counties Manukau Adult Mental Health Service operates following Sean\u2019s death.\u201d<\/p>\n
She said changes included \u201cimproved suicide prevention training for staff\u201d.<\/p>\n
\u201cWe have met with Sean\u2019s family and are more than happy to meet with them again to discuss the review,\u201d she said.<\/p>\n
\u201cWe remain committed to learning from Sean\u2019s 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.\u201d<\/p>\n
\u2018I feel like a massive failure\u2019: A sister\u2019s grief <\/p>\n
Leading up to the review, Kessels\u2019 mother, sister and two other family members provided letters about his life and the impact his death had on them. <\/p>\n
Just one was included in the official, complete review, written by his sister Courtney. <\/p>\n
It read: \u201cSean 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\u2019t seem fair that he got a life of pain and struggle and I didn\u2019t. And that\u2019s something that as a sibling will never go away.<\/p>\n
\u201cWhen I read the review on Sean\u2019s report, I couldn\u2019t believe the words on the paper in front of me.<\/p>\n
\u201cMy heart, that\u2019s already shattered, tore a little more for my brother. I always knew the system was bad, but to read that \u2026 was a painful moment of my life I\u2019ll never forget. <\/p>\n
Sean and his sister Courtney were very close. Photo \/ Supplied<\/p>\n
\u201cWhen 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\u2019t. He didn\u2019t grow up, leave and have children. <\/p>\n
\u201cHe was stuck in a world that as a young mum I didn\u2019t understand. I knew he was sick, but naively I thought he\u2019d have a good support team to guide him through this life. <\/p>\n
\u201cIt breaks my heart that I was wrong and I wasn\u2019t there for him more. Something I have to live with every single day; I feel like a massive failure to my brother.<\/p>\n
\u201cSean 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\u2019t. <\/p>\n
\u201cHe 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\u2019t even know how much because of this s*** illness.\u201d<\/p>\n
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>.<\/p>\nA Moment in Crime is a NZ Herald podcast.<\/p>\n","protected":false},"excerpt":{"rendered":"He had attempted suicide twice and had been admitted to secure facilities. His death was referred to Coroner…\n","protected":false},"author":2,"featured_media":585367,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[9526,38864,28824,1558,1559,5907,124,218578,8473,5904,9872,62821,305,134,296,5511,18220,288149,14571,2845,105885,3234,130,6178,2721,111,139,69,49160,762,62241,3546,213,8911,6211,6110,131,6859,6382,26229,1316,14905,102,10119,6730,379],"class_list":["post-585366","post","type-post","status-publish","format-standard","has-post-thumbnail","category-sports","tag-another","tag-answers","tag-arrived","tag-been","tag-called","tag-completed","tag-could","tag-disillusioned","tag-done","tag-final","tag-finally","tag-grieving","tag-have","tag-health","tag-into","tag-just","tag-kelly","tag-kessels","tag-kick","tag-leaving","tag-logan","tag-months","tag-more","tag-mother","tag-mum","tag-new-zealand","tag-newzealand","tag-nz","tag-prevent","tag-review","tag-ridiculous","tag-sean","tag-sports","tag-suicide","tag-system","tag-teeth","tag-than","tag-told","tag-took","tag-waited","tag-when","tag-whether","tag-with","tag-within","tag-would","tag-year"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/585366","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=585366"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/585366\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/585367"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=585366"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=585366"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=585366"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}