Coroner Mary-Anne Borrowdale has decided not to hold an inquiry into the death of Norman Lee, who died of pneumonia at Christchurch Hospital on 9 July 2020.
Lee, 90, was found by police in June 2020 locked in a cold, dark room that reeked of faeces, trapped in a wetsuit over adult nappies on a urine-stained mattress. The wetsuit zip-cord had been removed so he could not take it off himself.
Lee's son David Lee kept him locked in the room for up to 16 hours a day, often from 5pm until 9 or 10am. Light switches were taped into the off position, an electric heater was taped off, and a sheet covered the window, which was taped shut. There was no drinking water in the room and two cameras were trained on the bed.
The coroner found the cause of death was pneumonia and severe heart disease with a background of frailty and dementia, with elder neglect as a contributing factor. A post mortem found the neglect and living environment almost certainly increased Lee's frailty, exacerbated his dementia symptoms and increased the risk of pneumonia.
David Lee and another person were jailed in 2022 for abuse and neglect of Norman Lee and for stealing more than $220,000, which was spent on cars, entertainment systems, scooters and holidays. David Lee was sentenced to six years jail. Judge Callaghan described trapping the incontinent man in a wetsuit as "a form of torture".
Multiple Healthcare New Zealand carers, a social worker and at least one nurse visited Norman Lee but none raised concerns until days before police rescued him. When asked by a nurse how he felt living with his son, Lee said "terrible and awful".
Health NZ conducted an independent review that highlighted systemic issues and gaps and made a dozen recommendations. The Health and Disability Commissioner declined to release its investigation or comment on why it remained unpublished.