Inquest into Jordan Keil's Death Underway as Family Alleges Systemic Failures

On February 7, 2022, Jordan Keil, a 25-year-old man with a bright future ahead of him, was found dead in the garden of Middlemore Hospital’s secure mental health unit, just hours after escaping from a window. His mother, Debbie Thorpe, described the heart-wrenching moment she discovered his body mere metres away from the unit he had fled from, raising serious questions about the care he received during his final days.

Ms. Thorpe testified before the inquest into Jordan’s death, detailing a series of alarming failures by hospital staff during the eight days leading up to his passing. She recounted how security personnel were initially unaware of his absence, despite his disappearance occurring on the previous night. This lack of communication and response from hospital staff has left the family grappling with deep-seated concerns over the adequacy of mental health care in New Zealand.

Jordan was a former St Peter’s College 1st XV and water polo player, who had trained as an electrician and had traveled the world before returning to New Zealand to start his own business. In January 2021, Jordan was in a stable relationship, enjoyed a family Christmas and summer holiday, and was preparing to return to work. However, signs of severe mental distress began to emerge, including delusions and paranoia, which led his mother to take him to Auckland Hospital’s emergency department on January 31, 2022.

Ms. Thorpe described the events that followed as a nightmare. Jordan’s medical notes incorrectly indicated that he had been taking MDMA daily for weeks, despite his own admission that he had only used the drug a few times and had not used it in the week prior to his hospital admission. This misrepresentation, she said, skewed the approach taken by hospital staff, who treated him as a substance abuser rather than someone in need of mental health support.

After being discharged from the hospital, Jordan’s condition worsened dramatically. He began to speak of a bomb under his mother’s car and a gang plot to kill her. He grabbed the keys from his mother and ran away, only to be found later on a bridge, where he said he was going to jump. Following his return to the hospital, he was committed for treatment under the Mental Health Act based on substance abuse, despite the strong opposition from his family and friends.

Ms. Thorpe expressed concern over the inadequate escort provided by two female nurses, who arrived in a sedan to transport Jordan to Tiaho Mai. She voiced doubts about the suitability of the escort for her athletic and distressed son. During the journey, Jordan escaped from the moving vehicle, leading to an eight-hour ordeal on the Sylvia Park car park building, where he threatened to jump. His parents, Debbie and Mike Keil, remained at the scene, waiting for him to descend, and were deeply grateful for the efforts of the police in persuading Jordan to come down.

Following this traumatic incident, Jordan was taken to the secure mental health unit at Middlemore Hospital with injuries from his escape. However, Ms. Thorpe said that even then, the hospital failed to address the cultural needs of her family, with no consideration of tikanga Māori or any accommodation for whānau to stay with him. She was also insulted by the assumption that she might have smuggled substances to her son, despite her clear identity as a loving mother, school teacher, and law-abiding citizen.

Ms. Thorpe described the eight days Jordan spent at Tiaho Mai as a time of confusion and suffering. She alleged that there were issues with the medical notes, the diagnosis, and even confusion over which room he was in. During the inquest, it was revealed that Jordan escaped from the secure unit that night using a spoon to open a broken window, ultimately leading to his tragic death.

Coroner Rachael Schmidt-McCleave has stated that the inquest will examine the claims made by the family, as well as other aspects of Jordan’s death, in an effort to determine what changes could be made to prevent such a tragedy from occurring again. The inquest has already highlighted serious concerns about the systemic failures within the mental health care system, and it is hoped that the findings will lead to meaningful reforms.

As Ms. Thorpe said, “Jordan’s death has had a catastrophic impact on all our lives. Losing a child must be the most devastating thing that can happen to a parent.” The inquest into Jordan Keil’s death is not just a legal process—it is a call for change, and a reminder of the urgent need for improved mental health care in New Zealand.