It was supposed to be the safest place for him, but within hours of entering the Wairarapa Hospital Crisis Respite and Recovery Centre, 33-year-old Carterton man Benjamin Bowman was found dead. A year on, his family are still awaiting an apology, writes Emily Ireland.

Benjamin Bowman died in the Wairarapa Hospital mental health respite unit last March, leaving behind a wife and four children.

At his most vulnerable point, he was left alone, unsupervised.

He took his own life just 10 minutes after having dinner.

Now, a year on, his family have filed a complaint against the Wairarapa District Health Board to the Health and Disability Commissioner, in the hope they will get an apology.

“I want them to say they accept they could have done better,” Ben’s wife Ashleigh said.

“I also don’t want this to happen to anyone else. It doesn’t have to happen.

“I want his kids to look back and say, Mum fought for it to be recognised that Dad went for help and he didn’t get it.”

On Sunday, March 12, 2017, the night before Ben was admitted to respite, he was threatening to kill himself.

To get Ben the urgent help he needed, his wife Ashleigh called the after-hours mental health number and Wairarapa Hospital.

She couldn’t get through to anyone.

As a last resort, to protect Ben from himself, the police were called and he was held in their cells for three hours.

That weekend he had consumed “a lot of alcohol, and an unknown quantity of diazepam [antidepressant]” – a potentially lethal mix.

His wife and kids had been staying at her mother’s house with their children that weekend because Ben “wasn’t himself”.

“They didn’t need to see him at his lowest,” Ashleigh said.

“It’s like he had lost himself that weekend, and I was so scared I was going to lose him.

“We just wanted him to be safe.”

At the Police station, Ben was assessed by a crisis team, and dropped back home that night.

He did not have a house key and “had to smash the door to get in”, Ashleigh said.

To add to the cocktail of drugs and alcohol Ben had in his body, he was also given sleeping pills while in the care of the Police.

The next morning, Monday, March 13, with a potentially lethal cocktail of drugs and alcohol in his system, Ben was taken to the Wairarapa Hospital Emergency Department by his brother-in-law.

His hand was swollen after breaking into his house and punching walls, and he was still on a low.

According to a Wairarapa DHB-authorised serious adverse event report, made available to the Times-Age by the family, Ben was triaged at 7.05am and was seen by a doctor more than three hours later at 10.36am, when he confessed he had taken 10 5mg tablets of diazepam that morning along with “heavily using alcohol and cannabis”.

He was referred for assessment at the Wairarapa Hospital Crisis Respite and Recovery Centre, and admitted at 12.38pm.

Even after a potential overdose that morning, and with a history of depression from the age of 13 and suicidal thoughts from 14, Ben was deemed to be at low risk of killing himself that day, a decision which will haunt his family forever.

Ashleigh said after a lifetime of Ben “dealing with these people”, he knew what they wanted to hear.

“Ben has had mental illness since he was a teenager. He knew what people wanted to hear and that’s what I was stressing with everyone that day.

“I said, ‘he’s going to tell you what you want to hear’.

“He’s not going to sit down and talk through what is going on for him.

“That’s how he came back with a low-risk assessment even with everything I said to them.”

That day, after eating dinner in the respite unit at 5.30pm, Ben was found dead at 5.40pm.

The first that Ashleigh heard of her husband’s death was between 6-7pm with a phone call from the hospital saying, “Ben went and had dinner, then he had a smoke, and then we found him dead”.

She had been bathing her children at the time.

“I asked if I could come up and see him and he said ‘No, you’re not allowed to, the police are here’,” Ashleigh said.

She didn’t see her husband until he was in the funeral home.

In the months that followed, meetings were held by the Wairarapa District Health Board to discuss the incident with the family.

Ashleigh said she “could not physically attend” any of the meetings, because they were held at the mental health unit where Ben had killed himself.

She and Ben’s family have received no apology or acknowledgement that things could have been done better, Ashleigh said.

“They didn’t give him the care he should have received.”

“He should have been sent to a secure facility like the one in Porirua where he would have had the supervision he needed. . .  But they don’t take you seriously until you have actually attempted to kill yourself.”

Ashleigh said she felt “let down” by the lack of empathy from the WDHB.

“It’s like they haven’t even acknowledged that someone died in their care.

“It’s not giving him or his family any respect. We have received nothing, no apology.

“Ben was let down right from the beginning. He was told it would be the best place for him to be, and I was told he would be safe there, but he wasn’t.”

WDHB mental health, addictions and intellectual disability service general manager Nigel Fairley said he was not able to comment publicly about individual clients.

He said the Crisis Respite and Recovery Centre provided short-term mental health and wellbeing support for up to five people.

“It has two staff during the day, one in the afternoon and evening, and oversight from a registered clinical coordinator during the week.

“Additional support is available from the adult community mental health team nearby.”

“All incidents within our service are reviewed.

“This can involve having senior staff assess the incident and clinical files, or having an independent review carried out.

“Findings are shared with clients’ families, and are not shared more widely due to our privacy obligations.”

The serious adverse event report authorised by the WDHB concluded there were no organisation-wide recommendations.

It did, however, conclude that the disparity between the documentation of Ben’s mental health and suicide risk by his assessors, and the concern expressed by his family should be considered by the WDHB.

“If it is accepted the family’s account is correct, this should be acknowledged and respectfully conveyed to the family,” the report said.

Ben’s ashes were scattered yesterday.