The parents of a suicidal Dunedin student have spent almost 10 years desperately searching for answers.

Eleven days of evidence were heard in Dunedin Magistrates’ Court in 2020 and 2021, leading to a 123-page ruling issued by former coroner David Robinson about the 20-year-old. The death of Ross Taylor.

The coroner may have made recommendations to reduce the chances of further death in similar circumstances, but Robinson refused to do so.

Corinda Taylor, who founded the Life Matters Suicide Prevention Trust, said her son’s death on March 22, 2013 began “a decade of hell”.

“The worst thing… is that the trauma Ross went through and everything that happened after his death robbed me of my ability to remember good things.”

Corinda Taylor describes her son as smart, musical, athletic and artistic.

“He had a great sense of humor; as a family, we could always joke around together,” she said.

“He’s my youngest child and we have a great relationship.”

Ross Taylor’s deteriorating mental health led to psychosis and remained at Wakari Hospital, and while his condition improved over the next few months, there were signs of a relapse in late 2012.

While on holiday with his father Sid, Rose became aloof and anxious, having “paranoid thoughts and auditory hallucinations” during a visit to Wellington Hospital.

Returning to Dunedin in the new year, Ross was assessed by his psychiatric team as not psychotic or suicidal, despite his parents’ concerns about his substance abuse.

By February 2013, he had moved into a student apartment on Albany Street, and was described as “stable” after a home visit, despite having missed multiple clinician appointments.

Over the next month, his parents became increasingly concerned, repeatedly contacting Rose’s mental health team about his wayward behavior.

Sid said he believed a “tipping point” had come when his son called him to talk about a painting he had painted, and he was fascinated by the “third eye.”

Within days, roommates saw Ross set fire to his mattress and then throw a bucket of red paint on the road.

He was a heavy drinker at the time, and some said there were reports of him putting LSD tags in his eyes.

Ross showed up at his mother’s home on March 17, looking “scruffy, haggard and exhausted”, and she took him to treat the cigarette burn on his arm.

When consulted psychiatrist Dr Richard Mullen saw him the next day, he described him as depressed but wrote: “We did not see any subtle signs of psychosis. His mood was warm, lively and humorous. . He has no suicidal tendencies.”

The parents said they were “taken aback”.

On March 21, just hours before their son’s death, they were so concerned that they wrote a letter in response.

“We…continue to find that his behavior was completely out of character and not at all his usual self. Self-harm is a serious problem,” they wrote.

“We want to get a second opinion as soon as possible … that is long overdue and Ross is at great risk, as we have pointed out to you time and time again.”

His body was found at 8 am the next morning.

In 2017, the Health and Disability Commissioner found the Southern District Health Board had breached the code by failing to fully understand Ross Taylor’s condition.

“Overall, there is a lack of joint decision-making, care and crisis planning between psychiatric services, Ross and his family,” it said.

Dr Mullen was also criticised for failing to educate Ross about alternative treatments following a visit to Wellington Hospital in December 2012.

Robinson stressed that his role as coroner was not to find errors or reconsider them.

He ruled that Ross was probably not mentally ill when he died.

“While there is consensus that antipsychotics may reduce the likelihood of adverse outcomes, there is no diagnostic or clinical basis for their reintroduction in or around March 2013,” he said.

Robinson said Ross’ suicide may have been due to the death of another student around the same time, or because college proctors wanted to see him to address his wrongdoing.

Where to get help:
• lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth Hotline: 0800 376 633 or text 234 (available 24/7)
• Children’s Hotline: 0800 543 754 (available 24/7)
• How is this going: 0800 942 8787 (12pm to 11pm)
• Depression Helpline: 0800 111 757 or text 4202 (available 24/7)
• Anxiety Helpline: 0800 269 4389 (0800 Anxiety) (available 24/7)
• Rainbow Youth: (09) 376 4155
If it is an emergency and you feel you or someone else is in danger, call 111.