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Eccentric Kiwi musician Peter Gutteridge did not receive the care he needed at a mental health unit days before his suicide, a coroner has found.
Coroner Brandt Shortland released his findings after an inquest into the death of one of the founding members of the The Chills and The Clean in September 2014.
The inquest shone a light on Gutteridge's final days before he was found dead at an Auckland mental health unit, aged 53.
Days earlier, Gutteridge had returned to New Zealand from the only overseas trip he ever took, telling Customs officers he had 'messed things up'.
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Upon his return on September 12, 2014, he said he felt frustrated and the trip to America had not met his expectations, causing Customs officers to grow concerned about him.
He was admitted to a mental health unit, only to take his own life days later.
Coroner Shortland said Gutteridge was a well-loved family member, friend and a person who tried the best he could within his frailties and imperfections.
'It was clear that his hastily-arranged tour of the United States set in place a chain of events that led to his very unfortunate death,' he said.
'Perhaps he was unrealistic with his own expectations and his abilities, nevertheless he pursued his dream in the hope that he could revive somewhat of an enjoyment in playing with his old band ... only to feel a sense of failure.'
'In the end, his despair, anxiety from his first overseas trip; perception of failure in that he had let a lot of people down; and the fact he was in an unfamiliar mental health facility, a foreign environment all became too much and overwhelmed his ability to rise above it.'
Gutteridge had struggled with drug and alcohol addiction for most of his life, Coroner Shortland said.
In the years before he died, he had fought the battle with those addictions and 'got the heavy drugs out of his system'.
'It was clear to his family that his health and ability to function had improved greatly.'
During that time, Gutteridge continued to write music and was getting on with his life but was always prone to anxiety and was taking medication for it.
TRIP TO THE USA
In August 2014, Gutteridge left New Zealand for the first time and took a trip to the United States to try to meet up with his old band The Clean.
Friends helped him organise his travel, passport and got him on the plane, the report said.
The band had three sellout concerts to play in New York before they were set to go on tour.
'It appears, Mr Gutteridge had planned to turn up in New York knowing that The Clean were performing concerts there.
'There was a hope that he would bump into them and they would invite him with open arms to play with them,' Coroner Shortland said.
However, it appeared the meeting did not go to plan and Gutteridge organised a friend to extend his stay in the US.
Gutteridge then flew to Los Angeles and called his friend back in New Zealand telling him he'd smoked 'crack' and it had 'destroyed his mind'.
He said he felt like he had let a lot of people down.
His friend organised for Gutteridge to return to New Zealand and was concerned he had ran out of medication.
RETURN TO NZ
Upon arriving at Auckland Airport shortly after 5am on September 12, Customs staff observed Gutteridge appeared disorientated, unsure of his surroundings and unsure of what he was supposed to do.
Customs officer Gareth Davies told the inquest in 2017 he spoke with Gutteridge and said the artist did not immediately respond when he tried to talk to him.
'He said, 'Sometimes I go off into these little trances and I forget where I am. I have burnt all my bridges and have messed things up',' Davies said.
'I remember him being completely expressionless.'
Later that day, he was taken to Manukau police station where mental health services were called and he was assessed. He was then transported to Middlemore Hospital's Tiaho Mai mental health unit, where he was admitted as a patient under the Mental Health Act.
He had told a policeman he didn't really want to be assessed and wanted to return to Dunedin.
Sergeant Nigel Radovanovich told the inquest Gutteridge had voices in his head telling him to delete everything, including contacts and possessions.
During Radovanovich's time with Gutteridge, he disclosed he suffered from anxiety and hadn't been taken his medication.
Gutteridge was assessed by Dr Kalinowski at the police station and was found to be suffering from drug-induced psychosis. He was taken to Tiaho Mai.
FINDINGS
Coroner Shortland made a number of recommendations including having a senior doctor routinely rostered in the mental health unit at all times.
The Health and Disability Commissioner carried out a formal investigation after Gutteridge's death, with close examination of the care and treatment service at Tiaho Mai.
Coroner Shortland said the commissioner found, Tiaho Mai did not provide services to Gutteridge with reasonable care and skill.
Staff failed to arrange a psychiatric review and his risk was not assessed sufficiently following his admission.
The commissioner also found staff failed to respond to his changing moods and did not respond to concerns raised by Gutteridge's friends and family after he began talking about making a will.
'Whilst is it not for this jurisdiction to make comment, the Counties Manukau District Health Board were found to be in breach of the Code of Health and Disability Services Consumer rights.'
As a direct result of Gutteridge's death, the CMDHB mental health inpatient service underwent a major restructure to ensure a similar situation did not happen again.
Coroner Shortland extended his condolences to the family and friends of Gutteridge and thanked them for their patience.
WHERE TO GET HELP
Lifeline (open 24/7) - 0800 543 354
Depression Helpline (open 24/7) - 0800 111 757
Gambling Helpline - 0800 654 655
Healthline (open 24/7) - 0800 611 116
Samaritans (open 24/7) - 0800 726 666
Suicide Crisis Helpline (open 24/7) - 0508 828 865 (0508 TAUTOKO). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Youthline (open 24/7) - 0800 376 633. You can also text 234 for free between 8am and midnight, or email [email protected]
0800 WHATSUP children's helpline - phone 0800 9428 787 between 1pm and 10pm on weekdays and from 3pm to 10pm on weekends. Online chat is available from 7pm to 10pm every day at www.whatsup.co.nz.
Kidsline (open 24/7) - 0800 543 754. This service is for children aged 5 to 18. Those who ring between 4pm and 9pm on weekdays will speak to a Kidsline buddy. These are specially trained teenage telephone counsellors.
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