“This will be a difficult day for you,” says Dr Murray Jamieson to Shane’s parents. “And I want to express my sympathy.”

At their request, says the Auckland coroner, the court will hear “a recording by the late Shane Fisher, an accomplished guitarist”.

There’s an awkward moment. The music plays in fits and starts. The registrar gets up, sits down and then gets up again. Mercifully, the track settles and Shane’s melodious acoustic guitar and voice eerily fill the courtroom.

The tribute is a poignant reminder of a life cut short. The stuttering start has resonance too – Shane’s story has waited 29 months to be heard.

For years Shane lived in a world of spirits, visions and astral travel, a world where he saw himself as a leader of angels. But on May 18, 2006, with new medication, Shane reveals he does not feel controlled by spirits, does not see visions or hear the angels commanding him, and is not having thoughts put into his head.

The medication is clearly working, but there is a tragic side effect. The loss of his auditory hallucinations, his psychotic world, is also a loss of his identity. Shane is missing his angels and is talking about self-harm as a way of rejoining them.

Two days after the final review he was to have at Te Whetu Tawera, the Auckland District Health Board (ADHB) acute mental health unit which was caring for him, Shane was found dead at home.

The question at the centre of the inquest into his death is whether someone as unwell as Shane received the proper level of care. It’s a question that goes to the heart of the recovery-based ideology that guides our mental health services.

It’s a question that asks whether there are gaps in that service – whether it has the expertise and resources to deliver its goals.

Whether Shane was given the time and support he needed to get better, or whether a service under strain pushed him back into the community before he was ready. At the end of the two-day inquest, the coroner finds Shane’s death, on May 20, 2006, was self-inflicted and intentional and that no other person was directly responsible. Shane was 26.

Suicide. It’s what everyone knew when it happened, but only now, such is the legal taboo on uttering the word, can it publicly be uttered.

Normally, that would be the end of it – name, address, occupation, self-inflicted death – another statistic to add to the 500 or so who die this way each year. Our Coroners Act prohibits the publication of details of individual suicides. And no one can publish that the death was by suicide until the coroner says so.

But Shane’s case is different, largely because the family wants the inquest evidence made public. It’s an unusual circumstance disrupting the logic behind the Coroners Act: that the family and friends of anyone who commits suicide suffer enough grief without having it played out in the news media. Normally, suicide is nobody else’s business.

The Fishers disagree. They want the information to come out to highlight the plight Shane, and others like him, face under what they view as a mental health service in chaos.

Thanks to their courage, and Dr Jamieson’s lifting of the publication prohibition – in the hope some “good could come out of the death of a much-loved son” – the wall of silence of what happens in a suicide inquest is broken through…

…

What we can say is Shane was diagnosed schizophrenic, had attempted suicide before and was found dead at home, by his younger brother. The onset of his illness is thought to have been triggered by a traumatic event – the death in 1998 of his brother Glen of meningococcal septicaemia.

Glen was 17, a year younger than Shane. The family tragedy was compounded by a 2002 coroner’s finding of “poorly organised and inadequate” care at North Shore Hospital, which wrongly diagnosed Glen’s condition as an influenza-like illness when he arrived at the Emergency Department.

Sally Fisher recalls her previous experience in coroner’s court – coincidentally, also before Dr Jamieson – battling for Glen.

“Today I am once again confronted by lawyers – their fee being subsidised by taxpayer dollars. I find this distressing, disturbing and immorally wrong.”

She says the lawyers’ adversarial focus on achieving the best outcome for their client – “the sanitation of the truth” – doesn’t help either.

“The determination of DHBs to refuse responsibility and avoid culpability needs to be addressed.” As an example of insensitivity, she points to a letter from the ADHB apologising for the delay in writing to the family, as was agreed, following mediation. It was an apology that came 14 months late.

Fisher stays in combat mode for most of the inquest. Dr Jamieson often patiently reminds her that this is an inquiry into Shane’s death, not a commission of inquiry into the state of mental health services in New Zealand. And that she needs to frame a question rather than make a statement and allow those giving evidence, time to answer.

Fisher: Is Lorazepam addictive? Yes or no?

Coroner: You don’t need to say yes or no.

But she also takes time to talk about her son – the eldest of five children, intelligent, an avid sportsman, talented and passionate musician, keen surfer and conscientious student with a wide circle of friends. “He had a very full life and was a very happy and contented child, idolised and admired by his siblings … we were very privileged parents.”

At Rosmini College he obtained an A bursary in his seventh form year and also passed Trinity College exams for both speech and music.

In his school reference the headmaster writes: “Shane is an open, friendly, mature individual who comes from a very supportive family, responds positively to authority and relates well to peers and adults.”…

…Shane returned to Auckland where he was given fortnightly injections of Risperidone by the Community Mental Health team. He was readmitted to Te Whetu Tawera on Boxing Day in 2005, returning home in mid-February. Shortly after, Shane tells people he would “do away with himself” if the intolerable headaches he was experiencing didn’t cease.

He does attempt suicide on March 20 and is re-admitted. He remains in the unit with the right to unescorted leave until his death in May.

It’s during this period that psychiatric staff determine Shane is non-responsive to Risperidone. They are mindful that headaches and migraines are a documented side effect of the drug. But with a change in medication and a reduction in the headaches, another problem emerges. With the diminishing of his psychotic world, Shane is also feeling a loss of identity.

“While still psychotic but beginning to respond to treatment he told me on 10 April 2006 that he noticed the withdrawing of the angels, he was missing them and he considered self-harm to rejoin them,” says one of the psychiatric staff.

To read the article in its entirety go to Weekend Herald site here.