Warning: This story contains discussion of suicide

Vanessa Bishop struggled with suicidal thoughts most of her life. When she went to Tauranga Hospital for help, she hoped it would be a safe place. Instead, she died there. Tony Wall reports.

In 2015, Vanessa Bishop was in a good space. She hadn’t self-harmed or thought of suicide in about a year, she told Stuff, and with the help of a groundbreaking new model helping psychiatric patients in their own homes, was excited about the future.

But tragically, it all fell apart. Almost eight years later she died in Tauranga Hospital’s mental health inpatient unit, aged 30, in a suspected suicide that has led to an inquiry into procedures there.

Her parents say her death was “totally avoidable”. They claim not only was she not being monitored properly, but staff placed the equipment in her room that she is thought to have used to kill herself with.

The parents, Janey and Peter Bishop of Horowhenua, contacted Stuff after an article last week about Hauora a Toi Bay of Plenty and Te Whatu Ora Health New Zealand refusing to provide any details about a death at the unit last year, citing privacy grounds.

They believed their daughter’s case was the one Stuff wanted to know about.

Bishop died in the unit on December 2, six weeks after she was admitted, but they had yet to hear the results of a “serious incident review” being conducted by a consultant psychiatrist from Auckland and a senior mental health nurse from Waikato.

Stuff put a series of questions about Bishop’s care and the circumstances around her death to Hauora a Toi Bay of Plenty (the former Bay of Plenty DHB) but it says it can’t comment because the case is before a coroner.

A Justice Ministry spokesperson confirmed the case is before a coroner, but no further information is available.

Bishop had struggled with her mental health since the age of 12 and was diagnosed with complex post-traumatic stress disorder, chronic depression and borderline personality disorder. She also took medication for epilepsy.

She was passionate about helping others, her parents say, and had worked with a Tauranga Hospital consumer consulting group, speaking to new intakes of nurses about treating mental health patients with respect.

In a 2015 interview, Bishop said she had ended up in hospital after self-harming or threatening suicide over 100 times.

But with the help of Linc Support Services, she was flatting and making plans for the future.

“I want to be able to help people the way that I’ve been helped,” she said. “I’m quite keen to get a job, I’m quite excited to maybe do some travel – do things that people my age do.”

Her parents say she achieved some of her goals in the following years, completing a diploma in computer engineering, working as a computer technician at a Tauranga church and gaining a certificate in Christian ministry.

In 2018, she did a mission trip to Fiji and the Solomon Islands. She also volunteered for the Shining Light Trust’s Hope Project and helped care for her elderly grandmother.

She completed her programme with Linc and was discharged from its care in 2021.

But she suffered a setback that same year when she fell during a seizure, injuring her knee. She was left with complex regional pain syndrome and started using a wheelchair, forcing her to move out of her flat.

In October she went to Tauranga Hospital’s acute mental health inpatient unit, Te Whare Maiangiangi​, asking to be admitted.

The unit has been the subject of ongoing criticism by the Ombudsman over its use of seclusion.

According to her parents, she was turned away because she didn’t meet the criteria for admission, referred instead to the hospital’s emergency department.

There, she went into a toilet and attempted to kill herself, they say. She went into cardiac arrest but was resuscitated and admitted to Te Whare Maiangiangi’s secure unit under the Mental Health Act.

Janey Bishop says while Vanessa wanted to be admitted, she didn’t want to be “sectioned” under the Act as it could affect her employment prospects and she felt the secure unit was a “horrible place to be”.

The Bishops have learned about some of what happened to Vanessa inside the unit from meetings with doctors and social workers involved in her care.

While in the secure unit, she deliberately burned her arm with boiling water from a tap in a communal kitchen area, requiring a transfer to Waikato Hospital for skin grafts.

“Psychiatric patients shouldn’t be able to just burn themselves with boiling water – it’s fundamental,” Peter Bishop says.

On her return to the unit she was placed in a less restrictive ward. Her parents understand she was meant to be checked every 15 minutes, although they say that’s almost impossible on a busy psychiatric ward.

Rules for reporting suicide prohibit discussion of the method used by a person to take their life. All that can be said is that Bishop appears to have used equipment brought into her room.

She was found at about 6am – about 45 minutes after she was last checked and appeared fine, her parents say.

Peter Bishop says a risk assessment should have been carried out before the equipment was introduced. The hospital had effectively given her the means to kill herself, he says.

They should have known it was dangerous equipment, Bishop says, as there had been similar recorded incidents elsewhere. “It’s just breaking all your own rules.”

As for Bishop’s monitoring, unit managers said they were short-staffed due to several people being away with Covid and it was during a shift change, Peter Bishop says.

“They had a whole range of excuses.”

At the time of Vanessa’s death, discharge planning was underway, but she had asked to be transferred to a respite unit for 10 days instead of the usual five.

“She wanted 10 days, she didn’t trust herself still, that’s a red flag,” Peter Bishop says.

Debbie Brown, Bay of Plenty Health’s senior advisor for governance, says the organisation extends its “sincere condolences” to Bishop’s family.

“We are in the process of finalising the Serious Incident Review into this tragic incident,” she says. The family has the opportunity to be part of that process, she says.

Janey Bishop says Stuff’s article in 2015 showed how well her daughter was doing.

“We’re left wondering, what’s happened since that time? Why has she found herself in this situation that she didn’t feel safe in the community any more?

“Vanessa wanted change [to the system] and that’s the legacy we want her life to be seen for.”

• 1737, Need to talk? Free call or text 1737 to talk to a trained counsellor.

• Anxiety New Zealand 0800 ANXIETY (0800 269 4389)

• Depression.org.nz 0800 111 757 or text 4202

• Lifeline 0800 543 354

• Rural Support Trust 0800 787 254

• Samaritans 0800 726 666

• Suicide Crisis Helpline 0508 828 865 (0508 TAUTOKO)

• Yellow Brick Road 0800 732 825

• thelowdown.co.nz Web chat, email chat or free text 5626

• What’s Up 0800 942 8787 (for 5 to 18-year-olds). Phone counselling available Monday-Friday, noon-11pm and weekends, 3pm-11pm. Online chat is available 3pm-10pm daily.

• Youthline 0800 376 633, free text 234, email talk@youthline.co.nz, or find online chat and other support options here.

• If it is an emergency, click here to find the number for your local crisis assessment team.

• In a life-threatening situation, call 111.