Waitematā DHB says there are gaps in patient records in its mental health unit He Puna Wāiora that contravene its own protocols.
Watch Lisa Owen's full Checkpoint report here:
This follows two patients dying of suspected suicide within a week of each other in May.
Checkpoint last week revealed that both patients were on the lowest levels of observation - meaning they were only being checked and engaged with every hour.
That is despite the parents of the second patient who died warning He Puna Wāiora that he was at risk of killing himself and was actively seeking ways to harm himself.
Information obtained using an Official Information Request shows not all scheduled patient observations were being recorded at He Puna Wāiora - contrary to the DHB's own protocol.
Waitematā DHB said it was "not aware of any instances where inpatient observations have not been carried out to an acceptable level".
However, it said there were "occasional exceptions" when observations have not been reordered as "completed". This usually happened when staff were calming and protecting patients and "de-escalating a situation with an aggressive service-user".
In these situations, staff continued to observe patients but this might not be be formally recorded as the priority was maintaining safety and managing the situation, it said.
Waitematā DHB's protocols say records must be maintained without any omissions, and entries should never be recorded retrospectively.
The DHB and Health Minister David Clark declined to be interviewed.
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 (24/7). 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 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
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Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.
