A broad list of changes has been recommended to improve the function of the Waitematā District Health Board's He Puna Waiora inpatient mental health unit.
The He Puna Waiora inpatient mental health unit. Photo: RNZ
An independent review commissioned after the deaths of two patients from suspected suicide in May 2019 has identified "systemic and culture issues" existed at the time.
The DHB said in releasing the results today that it accepted it was responsible.
Among eight key recommendations was a need to prioritise strengthening the unit's leadership and culture.
That included a review of leadership positions, developing procedures for consistent and responsive leadership engagement, and developing an organisational cultural framework.
The second recommendation suggested ways to work towards better focus on consumers - family and whānau.
Strengthening the model of care, implementation of a primary nursing model at the unit, and improving relationships between the unit and the wider social services system were also recommended.
The review also made a recommendation beyond the Waitematā DHB, in that it could be time to consider a national, centralised approach to the design of acute mental health inpatient units.
DHB mental health director Derek Wright said it accepted the findings unconditionally and would implement them in full.
He said parts of the report were "confronting" and many of the recommendations had already been addressed, while the review was in progress.
"We will keep going until everything in the report has been implemented," Wright said.
He said it was not possible to turn back time but the board could learn from the past and make changes that would "minimise the potential for inpatient deaths in future", while recognising that it was impossible to remove all risk.
Wright acknowledged the staff at He Puna Waiora for their ongoing commitment to patient care.
He said staff at the unit were highly skilled professional clinicians, who would be further supported by the recommended changes.
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)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
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.
