The mental health watchdog says the level of nursing care provided to a man in a psychiatric inpatient unit was unacceptable.
Mental Health Commissioner Kevin Allan said Counties Manukau District Health Board breached patient rights over the case in 2014.
In a report released today, Mr Allan said the unnamed man, Mr A, was found by police wandering outside an airport following an overseas trip.
He appeared dazed and confused and was taken to a police station where he was assessed by a consultant psychiatrist and a social worker.
The psychiatrist believed the man was suffering from psychosis, possibly drug induced or associated with a mood disorder. Mr A was admitted directly to the psychiatric inpatient ward under a compulsory treatment order, and was placed on observation every 15 minutes.
Shortly after his admission, he was reviewed by a consultant psychiatrist who wanted further assessment and monitoring.
Despite this, Mr A was not reviewed again. Instead, his history of substance abuse, chronic pain and anxiety was compiled, but there was no risk assessment done.
Friends 'very concerned and distressed'
On the Saturday Mr A's mood "appeared low" but he was subdued and kept to himself.
Two friends who visited him the next day told a ward clerk they were "very concerned and distressed as he had told them he was not going to come out of here alive", the report said.
"They were concerned that he was going to try and kill himself."
The friends added that Mr A had expressed thoughts about wanting to make a will, and had begun to identify himself as the "Messiah".
Early the next morning a staff member said Mr A was acting differently than before, but it was not unusual in that setting. He was told to stay in his room until breakfast at 6am. A psychiatric assistant saw him slam the door, then sitting on his bed looking away, and then pacing.
Level of nursing care 'unacceptable'
Close to 6am Mr A asked for two more blankets and he was seen at 7.15am lying on his bed, apparently sleeping. When a nurse realised close to 8am that he had not been seen having breakfast, another nurse went with a student to nurse to check. He was found unconscious and could not be resuscitated.
Mr Allan said the DHB's own review and an external review found failures. As well, the DHB told the HDC that the on-call psychiatrist "did not routinely attend the inpatient unit 'after hours' (including weekends and public holidays), and usually attended only at the request of the registrar."
Mr Allan said he could not determine the cause of death. But he said each of the clinical staff members who were responsible for Mr A over the weekend should have looked at his records, seen that the requested medical review had not occurred, and made arrangements for it.
He added that nursing staff "did not respond appropriately to Mr A's changes in mood and behaviour", adding the level of nursing care was unacceptable.
The DHB breached patient rights because its staff failed to arrange the review; because Mr A's risk was not assessed sufficiently; because staff failed to monitor him for signs of withdrawal; and for a failure of staff to respond to concerns raised by his friends.