Middlemore staff failed to ‘follow best practice’ in restraint of mental health patient - inquiry

6:50 pm on 25 November 2022
The Tiaho Mai acute mental health inpatient unit at Middlemore Hospital.

The Tiaho Mai acute mental health inpatient unit at Middlemore Hospital. Photo: LDR / Te Whatu Ora

Te Whatu Ora has released findings of an internal investigation into the alleged assault of a patient by a staff member at Middlemore Hospital's Tiaho Mai Mental Health Unit last month.

The unit provides 24-hour treatment services for people with serious or complicated mental health issues.

The family of the 24-year-old Tiaho Mai patient alleged he was assaulted on 22 October after refusing to take medication and was subsequently punched in the face and then kicked by a staff member while on the ground.

His brother said he was left with bruising on his legs and ribs. The patient has bipolar disorder and was admitted to the unit days before the incident.

In two reports into the events, Te Whatu Ora Counties Manukau said while the patient had not been assaulted, staff failed to follow proper procedures when restraining him.

"All staff are trained in applying safe holds working in a three-person team," it said. "However, in this incident two staff were forced to apply safe holds without a third staff member in the room."

The investigation found it was a departure from best practice because a three-person team was not used to restrain the patient and the panic alarm system was activated to alert other staff to the event.

"A three-staff team ensures that while both upper limbs are held in level four safe holds position by two staff on either side of the service user, the third staff member supports the upper shoulder, neck and face in the event the service user is brought down to the floor, preventing injury to the head and face.

"At the point of both staff members attempting to hold the patient's arms, they all fell to the ground, causing minor injury to the patient's inner lip. This injury was immediately reported and reviewed by a house officer later in the night."

The patient was "reviewed again" the next morning by a different staff member who found no "signs suggestive of an assault" and no further medical diagnosis was sought.

Te Whatu Ora Counties Manukau said it was sorry the incident had "caused significant distress and concern" for the patient's family.

The family has been approached for comment.

The incident is still subject to a complaint to the Health and Disability Commissioner.

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