Southern DHB failed mental health patient, commissioner finds

Southern District Health Board chief medical officer Dr Nigel Millar

Southern District Health Board/Stuff

Southern District Health Board chief medical officer Dr Nigel Millar

The Southern District Health Board failed to provide a proper treatment plan for a man who later committed suicide, seemingly on hospital grounds, Mental Health Commissioner Kevin Allan has found.

In a report released on Monday, Allan said medical and nursing staff failed to assess the patient, adequately, record key information about him, and formulate a diagnosis.

This was despite the man’s well-established history of mental illness and suicide attempts, Allan said.

“[These] failures meant that there was a lack of an easily identifiable, current and comprehensive treatment plan,” he said.

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Board chief medical officer Niger Millar said staff had acknowledged their mistake and apologised to the family.

“The staff involved are sincerely committed to the best outcomes for everyone in our care and to ensuring lessons are learned where the worst eventualities are realised,” he said.

The man, identified in the report as Mr A, was admitted to an open ward of the DHB’s inpatient mental health unit for compulsory treatment, following an attempt to self-harm, in 2017.

He suffered from major depressive disorder, anxiety, and obsessive compulsive disorders.

Allan found several problems during Mr A’s stay at the mental health unit– most of them centred around the consultant psychiatrist’s inadequate documentation of his decisions and planning, and his communication with other staff involved in the man’s care.

Nursing notes showed that a day leave visit did not go well, and Mr A was discovered missing from the ward during a routine check the next day.

It wasn’t until almost 24 hours later, with police help, that he was found on the hospital grounds, dead from apparent suicide.

Allan heard that medical staff failed to notify Mr A’s family, believing it was police’s job to do so.

The commissioner recommended that the board extend a formal apology to Mr A’s family, that complex cases be targeted for multidisciplinary review, and that comprehensive treatment plans be developed in collaboration with patients and their family.

Millar said the Mental Health Addiction and Intellectual Disability Directorate was working through Allan’s recommendations and findings.


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