Foul play ruled out as cause of 23-year-old Sheldon Tutai's death

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Warning: This story deals with suicide and may be upsetting.

A coroner has found no evidence the death of a young man with paranoid schizophrenia and substance abuse disorder was at the hands of drug dealers over a possible drug debt.

Instead, 23-year-old VJ Sheldon Tutai's death in a Hamilton school playground in the early hours of September 8, 2018 was self-inflicted, according to coroner Matthew Bates.

Tutai was discharged from the Henry Rongomau Bennett Centre at Waikato Hospital into the care of community mental health in September 2017.

Though he was loved by his whānau, his mother told an inquest into his death in September 2023 that Tutai couldn't return home to Tokoroa on discharge because his father had just been diagnosed with terminal cancer.

Instead he moved to a support home in Hillcrest managed by Connect Services (now Ember Korowai Takitini), according to the coroner's 88-page finding released today.

But it was just a few doors down from a drug house and Tutai used his meagre $25 per week allowance and food to buy synthetic cannabis on a regular basis.

In February 2018, Tutai attacked his friends while under the influence of the drug, prompting Connect staff to visit police and alert them to the ongoing sale of drugs from the Carrington Ave property to Connect residents.

The staff wanted police to visit the property because without the names of the alleged drug dealers, Connect could not trespass them.

Despite an online report, police did not attend the house.

The situation came to a head on 26 August, 2018, when Tutai suffered a seizure after getting high. He was found in the Connect house driveway frothing at the mouth and unable to stand.

He had cuts to his arms, wrists and hands and bruising to his wrist and under his left eye, and earlier he'd asked staff to hide him when a carload of people arrived at the house looking for him - telling staff the driver was a "local drug dealer".

The service leader again raised concerns about the tinny house with police as well as contacting Crimestoppers to report drug-related activities, and made an anonymous complaint to Kāinga Ora in the hope the occupants would be removed.

"Unfortunately, not enough detail was known regarding the occupants to enable trespass notices to be served."

Tutai's whānau told the coroner there was nothing stopping their son and brother from being able to associate with undesirable individuals both onsite and offsite.

"I have some sympathy for whānau's concerns that police did not follow up reports of persons at a nearby house supplying drugs to Connect residents," coroner Bates wrote.

"In my view, had police followed up reports at the time it would have been possible to identify particular persons and have them trespassed from Connect."

However, the coroner said that wouldn't have prevented Connect residents from associating with them offsite because the support house was not one that restricted the movements of its residents.

In an effort to prevent Tutai and other residents from obtaining drugs, their food was combined and meals cooked and eaten together instead of individually.

Tutai was put on a restricted meal programme where he was only allowed to eat meals and snacks in the whānau house, and his weekly allowance was taken away.

The day before he died it was reinstated at $7 a week.

On the night Tutai died, he went to bed before midnight after taking his medication.

A nurse checked on the residents at the usual times of midnight, 3am and 6am.

But a nurse, who had just finished a shift at Waikato Hospital and was working there full-time while working shifts at Connect, did not go into Tutai's room during the 3am check as he should have.

Instead he shone a torch through the window and saw a lump in the bed he assumed was Tutai.

In fact, CCTV footage at the nearby school where Tutai's body was later found, showed him walking in the school grounds about 2.30am.

The method by which Tutai died cannot be reported.

The nurse discovered Tutai missing at 6am but did not alert anybody because Tutai often went for early walks.

The nurse's work performance and record-keeping was the subject of a Health and Disability Commissioner's investigation and coroner Bates said he did not deviate from those findings, and he did not believe the nurse's actions contributed to Tutai's death.

Coroner Bates said Tutai, who loved music and sport and was popular before he developed mental health problems at 16, had talked about suicide several times in the past.

The coroner said while there was no indication Tutai would harm himself, there were stressors in his life at the time he died.

These included his father's cancer, although it was unclear if he knew his father was terminally ill, reduced visits from whānau and no visits home because of his father's illness, the loss of several key support workers, the difficulty he was having obtaining drugs and a potential drug debt, and the meal, mobile phone and weekly allowance restrictions.

"This would have been a source of stress for him, likely compounding his low mood due to drug withdrawal."

Despite the family's concern about a possible drug debt revenge, the coroner found no evidence anyone else was involved in Tutai's death and ruled it self-inflicted.

He recommended Connect consider refining its security check practice by requiring staff to make a record of each check at the time it's made, consider implementing a policy specifically to address threats of violence from visitors, and a policy to provide some monitoring of residents using the internet.

Coroner Bates also suggested Connect could revisit its policy of waiting 24 hours before reporting a resident's unexplained absence to police.

Connect, now Ember, said its policies and practices had evolved since Tutai's death and its bullying and harassment policy now made specific reference to harassers who may not be known to staff.

It also allowed for a missing person's report to be made within 30 minutes of a resident not returning.

Waikato Police also said since Tutai's death, a criminal investigation bureau (CIB) member must attend all sudden death and suicide scenes, which wasn't a requirement at the time and one did not attend at Tutai's.

The police had also restructured the coronial inquests workgroup to include a detective, and the group now reported to a detective inspector.

Where to get help:

• Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
• Lifeline: 0800 543 354 or text HELP to 4357.
• Suicide Crisis Helpline: 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.
• Depression Helpline: 0800 111 757 or text 4202.
• Samaritans: 0800 726 666.
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
• What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
• Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
• Rural Support Trust Helpline: 0800 787 254.
• Healthline: 0800 611 116.
• Rainbow Youth: (09) 376 4155.
• OUTLine: 0800 688 5463.

If it is an emergency and you feel like you or someone else is at risk, call 111.

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