17 Dec 2020

Flaws revealed at Waitematā mental health unit after two suicides in a week

From Checkpoint, 5:13 pm on 17 December 2020

A North Shore inpatient mental health unit where two people died by suicide within a week of each other was not up to standard and Waitematā DHB knew it.

An independent review into the deaths at He Puna Wāiora in 2019 highlights several serious concerns including:

  • A strong reliance on treating people with mediation rather therapies
  • Early discharges without robust planning as beds were needed for others
  • Six-month wait times for talk therapies for people discharged but still in the DHB's care
  • Inadequate leadership, burnt out, inexperienced staff and not enough of them
  • No effective primary nursing system
  • Unsafe elements in the actual building design.

Staff had raised such issues prior to the deaths.

Whānau interviewed for the report believed their loved ones had experienced neglect, humiliation, stress and a lack of dignity, respect, support and therapy at the hands of the DHB.

As well as the two inpatient deaths, the report also confirms the deaths of two other people by suicide who were also in Waitematā's care, one as an outpatient, the other at a respite facility.

"We want to publicly apologise to the families, because this has been a tragedy and clearly there were some deficits in our care," Waitemata DHB's Director of Mental Health Services Derek Wright told Checkpoint.

"We've written to the families a letter of apology. We also just want to acknowledge that we fully accept the recommendations within the review report.

"There were issues in terms of the care that we provided to these two young men."

However the report reveals there were two additional suicides related to the mental health unit.

"There was a suicide of a young man in the community who had been in the unit I think two months previously. And there was a suicide or suspected suicide of a person who was in a respite facility in west Auckland," Wright said.

"I don't know if the DHB knew about all the shortcomings because obviously the individual adverse event reviews that were undertaken when the suicides took place identified a number of areas that needed to be reviewed and recommendations were made.

"We started to work on them straight away, so things like the model of care."

The report reveals staff had raised concerns about issues like the design of the building as nurses did not have direct lines of sight for at-risk patients. That had been raised prior to the deaths.

"We knew that there'd been changes to the building… one of the issues we have is we don't have a standard design for inpatient units in New Zealand," Wright said.

 "The DHB thought that we had put in systems and processes that would actually assist. Clearly they didn't, which is why there's further recommendations and further work that needs to be done.

"Staffing is an issue throughout New Zealand. We recruit a lot of people from overseas because we don't grow enough mental health nurses in this country. And that's partly about the way mental health nurses are trained, very different to the years ago when I trained as a mental health nurse.

"Although there was issues in terms or recruitment, those rosters were full," he said, although many of those were casuals and staff working overtime he said.

"A number of the staff that we recruit come from overseas and that takes time, as well our homegrown nurses, so we take the new graduates, we have a number of staff and students who come on placement with us and obviously we recruit into them, we have a new nurse program that we run, so we bring about 20 nurses in into that programme every year as well. So we're trying really hard to make sure that we've got enough nurses, enough clinical staff."

In hindsight though Wright said not enough was done to keep two people from losing their lives.

The report also detailed concerns that patients were being overmedicated. But Wright said that does not amount to a form of chemical restraint.

"I think we've got good evidence to show that. We've got the lowest seclusion rate in the country. And there's been a programme that's been run by the Health Quality and Safety Commission for the last five years.

"What that's shown is that our staff actually worked actively with the clients to make sure that we can deal with situations where a restraint, or an incident may occur.

"There's no evidence that to do that they're using more medication.

"We'd always like to have more therapists, we've actually increased the number of psychologists. We've also increased allied health assistance at the weekends so that we can run extra programmes at the weekends.

"When you're in an inpatient unit one of the issues is actually making sure there's enough activities to keep you stimulated as well. In some situations that probably wasn't happening as well as it could have.

"We may well have had the balance [of medication] wrong in hindsight, but at the time we actually believe that the balance was about right."

He said he accepts the view from staff that there was overmedicating. "That's why we're trying to change the balance to ensure, and we've already put in more programmes, and we've put in more psychologists."

Regarding the two suspected suicides who were not at He Puna Wāiora, Wright said they would have had crisis and recovery plans in place.

"But there were plans in place, whether they were followed I can't say.

"One of them had been in the community for about a month and was being regularly followed up. So they would have had a plan in place, and they were being regularly seen by their community nurse. The other person was in respite facility.

"The person in the community as far as I'm aware… they were using private psychologist."

UPDATE: After the interview Waitematā DHB contacted Checkpoint over an inaccuracy in Derek Wright's comments. The family of the person mentioned above contacted the DHB to clarify he was not under the care of a private psychologist, as Wright had said. 

The person was on a wait list for a publicly-funded therapist when they died. 

"We are sorry to have not stated this correctly," the DHB said in an email