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.

READ MORE:
* Report finds Southern DHB failings in providing care to woman
* District health board criticised over care of man who died in psychiatric ward
* SDHB mental health patient dies after receiving inadequate care
* DHB, psychiatrist fail man who took his own life while in care

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.

WHERE TO GET HELP:

1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor

Lifeline – 0800 543 354 or (09) 5222 999 within Auckland

Youthline – 0800 376 633, free text 234 or email talk@youthline.co.nz or online chat

Samaritans – 0800 726 666

Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)

What’s Up – 0800 942 8787 (for 5–18 year olds). Phone counselling is available Monday to Friday, midday–11pm and weekends, 3pm–11pm. Online chat is available 7pm–10pm daily.

Kidsline – 0800 54 37 54 (0800 kidsline) for young people up to 18 years of age. Open 24/7.

thelowdown.co.nz – or email team@thelowdown.co.nz or free text 5626

Anxiety New Zealand – 0800 ANXIETY (0800 269 4389)

Supporting Families in Mental Illness – 0800 732 825