Dave Macpherson: The definition of incompetence…..


If you knowingly run or manage a health system that leads to avoidable deaths of patients, and you don’t change the system or the key personnel when you are aware of the problems, you can fairly be described as incompetent, and/or culpable.

In the case of the lack of care for Chelsea Brunton, a patient in the Mid-Central DHB’s ‘Ward 21’ at Palmerston North Hospital, a litany of errors – born of incompetence and a lack of caring – led to what a weak-kneed Coroner has now described as her death in 2017 by ‘suicide’.

They are the same types of ‘errors’ that occurred before Chelsea’s death, since Chelsea’s death, and are continuing to this day.

A cursory glance at the facts, not to mention the similarity with our son Nicky’s death in 2015, show that ‘negligent homicide’, or at the very least ‘assisted suicide’, would be far more accurate descriptions of the cause Chelsea’s death.

When Chelsea was admitted to Ward 21 as a voluntary patient on May 1st, she and her whanau were entitled to believe that her situation would improve as a result of a respite under the care of mental health professionals, or at least that she would be safe while in their care.

Sadly, she died under the DHB’s care, after being let out of the Hospital on an unsupervised cigarette break, by mental health ‘professionals’ and a mental health system that were aware Chelsea was feeling suicidal.

Chelsea and her mother were told, when she signed into Ward 21, that a nurse or other staff member would supervise her on any smoke breaks. However the same day staff were told by Chelsea that she felt suicidal, ‘but didn’t have a place in the Hospital to act on that’, she was let out unsupervised for a smoke. The next day, she was let out unsupervised again, and disappeared for four days until her body was found only about a block from the Hospital.

The Coroner found that the ‘most concerning problem was granting Chelsea unescorted leave….without an adequate risk assessment by a nurse, and without adequate documentation…’.

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During Chelsea’s four-day ‘absence’, after being let out unsupervised, Chelsea’s whanau received no liason from hospital security about where it had looked for her, leading to the whanau itself search the buildings and grounds (something we vividly remember following Nicky’s disappearance).

If this set of circumstances doesn’t demonstrate culpability and incompetence on the part of the DHB, its management and responsible staff, I don’t know what ever would!

The Coroner has not only ruled Chelsea’s death a suicide, but stated officially that there is no need for him to make recommendations because the problems highlighted by Chelsea’s death ‘have been dealt with by the Mid-Central DHB’!

Perhaps the Coroner was ignorant of the death of Simon Oakley only a month later, when granted leave from the same Hospital?

Perhaps he was ignorant of the deaths of Shaun Gray and Erica Hume while patients at the same hospital in 2014? (No inquests for these three victims have yet been held).

Perhaps he is ignorant of the highly similar circumstances surrounding the death of our son, Nicky Stevens, while a Waikato DHB patient only two years earlier, when he was let out unsupervised for a cigarette break against our whanau’s expressed and acknowledged wishes.

Perhaps he is a time-server, in a well-paid job, who doesn’t want to rock the boat after seeing the rather braver Coroner in Nicky’s case, Wallace Bain, get a bollocking from the state-funded patch-protectors in Waikato DHB after sheeting home the blame to the DHB?

Whatever the reason for the Coroner’s uselessness, Chelsea is dead and the DHB was not even ordered to provide an official apology to her whanau.

Health Minister Andrew Little needs to take an independent and vigorous look at what happened with Chelsea’s death – and at the circumstances surrounding many other deaths in recent years of mental health patients in the care of health services – not one sanitised through reports from Saint Ashley and his MoH and DHB minions.

It was not acceptable under a National Government – as Little himself said while Labour Party Leader in 2016 – for people seeking help and support from our mental health services to die while in their care. It is equally unacceptable for this to happen under a Labour Government, and just as unacceptable for the same mental health system leadership to be presiding in 2021, as was presiding in 2014, 2015 and 2017 – as it still is.

Dave Macpherson is TDBs mental health blogger who lost his son to the mental health system.


  1. You cant blame the mental health staff for what happened to Chelsea. I tried to get someone to take my sister out for a smoke while she was in mental health care I even called a Maori health provider neither would or could do this. If they let my sister go for a smoke she would have done the runner. The mental health system is under a lot of stress as is our public health system. We need to hope our government can fix our mental health and public health system both which require money and resources including well trained staff and health professionals.

  2. Andrew Little is the problem here he is in charge of health and is a seriously flawed minister . He is behind keeping New Zealand health system at the bottom of OECD and in collaboration with National in trying to turn our publicly funded hospital system into a private system by seriously underfunding the public health so people have no choice are the only people using the public health system

  3. You did lose credibility with “Saint Ashley” comment however I do agree that mental health needs a leadership overhaul given this goes back to 2014. In my personal experience those at a corporate level like to rule with a stick. This leads to all levels with some staff ruling with a stick. In other words, it’s not exactly a “therapeutic” environment. Massive under investment in both facilities and quality staff I believe is our biggest issues but this is driven from a corporate level. One example, my manager constantly raises issues about the substandard facilities we have to work in, in regards our early 70’s building, the cold nature of the building, the dampness( we have a directive of no fan heaters in the building) the roof leaks in the corners and onto carpet. The issues raised were met with, “if you don’t like it, we will put you into a worse facility”, that coming from a governance level. Staff at times are treated worse than our clients.

  4. In the Old days they had dedicated Mental Health facilities or Asylum’s, like Oakley Hospital & Kingseat, who specialised in treating people suffering from these Mental Conditions. Since they closed them all down & pretty much turfed these people out on the Street or housed them in halfway houses, jail or through Mainstream Hospitals, it’s been a disaster? Reopen dedicated Facilities that specialise in Mental Health which will take the pressure of our Hospital system?

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