Parents of man who died at Palmerston North Hospital's mental health ward say his death was avoidable

A coronial inquest into the death of 30-year-old Shaun Gray, who died at Palmerston North Hospital's mental health ward, has finally begun over eight years after his suspected suicide.

Christine and Ian Gray are still mourning the loss of their son, a loss they believe the health system could have prevented.

"So many parts of the system fell down and collapsed, his death was avoidable," Ian said.

Shaun died in April 2014. The family's waited eight long years for answers.

"While some of the delay, not all of it, some of it's been unavoidable - all of it nonetheless is regrettable," Coroner Matthew Bates said. 

Evidence revealed Shaun had been prescribed nearly three times the standard dose of methadone by his doctor, Sarz Maxwell.

"He was just like a walking zombie and no one seemed to care," Christine said. 

The US doctor was using opioid replacements herself, but the DHB didn't know when they hired her.

Medical Officer Dr Kenneth Clark said he was not aware of any disclosures by Dr Maxwell at her time of appointment, but "subsequently became aware".

A key issue is whether the reduction in Shaun's high dosage contributed to his suicidal tendencies.

He was taken to Palmerston North Hospital the day before he died after taking a variety of prescription drugs, injecting himself and then collapsing.

One witness, who we can't identify, broke down in tears and expressed concern about his medication.

"There appeared to be a reduction and I felt this would also be adding to his distress," they said.

The court heard how the hospital was understaffed the night Shaun died, his intention to self-harm was not written in the handover notes and some staff didn't want him admitted to the high-dependency unit.

"Her comment was 'we do not want this man'," the witness said.

"So many people have died since Shaun, what's happening up there, why are these people dying?" Christine asked. 

"They are vulnerable people that deserve respect and care."

Health care that will be under scrutiny for the rest of the inquiry.