Eleven days of evidence heard in the Dunedin District Court in 2020 and 2021 led to a 123-page decision, released today by former coroner David Robinson regarding the death of 20-year-old Ross Taylor.
Coroners may make recommendations to reduce the chances of further deaths in similar circumstances, but Mr Robinson declined to do so.
Corinda Taylor — who founded the Life Matters Suicide Prevention Trust — said the death of her son on March 22, 2013, began "a decade of hell".
"The worst thing ... is this trauma of what happened to Ross and everything after he died has robbed me of the ability to remember the good things."
Mrs Taylor described her son as intelligent, musical, sporty and artistic.
"He had such a good sense of humour; as a family we could always joke together," she said.
"He was my youngest little baby and we had such a good relationship."
During a holiday with his father, Sid, Mr Taylor became detached and anxious, presenting at Wellington Hospital with "paranoid ideations and auditory hallucinations".
On their return to Dunedin in the new year, Mr Taylor was assessed by his psychiatric team as not psychotic or suicidal, though his parents were concerned about his substance use.
By February 2013, he had moved into a student flat in Albany St and although he repeatedly missed appointments with clinicians, he was described as "stable" after a home visit.
Through the following month his parents became increasingly concerned, repeatedly contacting Mr Taylor’s mental-health team about his wayward behaviour.
Dr Taylor said he believed a "turning point" came when his son called him to talk about a picture he had drawn, obsessing over the "third eye".
Within days, flatmates saw Mr Taylor set his mattress on fire and later throw a bucket of red paint over the road.
He was drinking excessively at the time and one said there were reports of him putting an LSD tab in his eye.
On March 17, Mr Taylor turned up at his mother’s home looking "dishevelled, gaunt and exhausted" and she took him for treatment for cigarette burns to his arms.
When consultant psychiatrist Dr Richard Mullen saw him the next day he described him as demoralised but wrote: "we saw none of the subtle signs of psychosis. His mood is warm, animated and humorous. He is not suicidal".
The parents said they were "flabbergasted".
On March 21, just hours before their son died, they were so worried they penned a letter in response.
"We ... have continued to find his behaviour totally out of character and not his usual self at all. Self-harm is of serious concern," they wrote.
"We want a second opinion ASAP ... This is long overdue and Ross is at great risk, as we have pointed out to you repeatedly."
His body was found at 8am the following day.
In 2017, the health and disability commissioner found the Southern District Health Board had breached code by failing to appreciate the full picture of Mr Taylor’s condition.
"Overall, there was a lack of joint decision-making and care and crisis planning between the Psychosis Service, Ross, and his family," it said.
Dr Mullen was also criticised for failing to make Mr Taylor aware of alternative treatments following his visit to Wellington Hospital in December 2012.
Mr Robinson stressed his function as coroner was not to find fault or reconsider those matters.
He ruled Mr Taylor was probably not psychotic at the time of his death.
"While there is a consensus that an antipsychotic could have reduced the potential for an adverse outcome, there was no diagnostic or clinical basis for its reintroduction in or about March 2013," he said.
Mr Robinson said Mr Taylor’s suicide might have been prompted by the death of another student about the same time or by the fact the university proctor wanted to see him to address his errant behaviour.
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