12 Feb 2024

Mental health service failed patient who died in its care, watchdog finds

5:25 pm on 12 February 2024
A medical professional takes notes while talking to a female patient.

A community mental health service and health board have been asked to apologise to the family of a woman who died in an acute unit. File photo. Photo: 123RF

Warning - This story discusses suicide.

An Auckland mental health service failed to provide proper care to a patient with a history of self-harm who died in its care, a health watchdog has found.

The woman was in her 20s when she was admitted to Counties Manukau District Health Board's community mental health service in 2016.

The Health and Disability Commissioner's report, released on Monday, said she had a history of self-harming and life-threatening behaviour and was admitted to the acute unit for a seven-day stay, which was later extended.

The mental health service provides around the clock support for patients with an acute episode of mental illness, as an alternative to hospital admission.

The woman had been diagnosed with an eating disorder, attention deficit hyperactivity disorder, partial post-traumatic stress disorder, alcohol use disorder, traits of a personality disorder, anxiety and depression.

"Throughout her stay, the woman struggled with ongoing low mood and suicidal thoughts. Sadly, the woman was found in her room having died by suicide," the report said.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the health board - now Te Whatu Ora Counties Manukau - and mental health service breached the Code of Health and Disability Services Consumers' Rights for their care of the woman.

She found they failed to properly pass on important care notes to the support specialists and did not conduct a face-to-face psychiatric assessment before deciding not to move the woman to a secure in-patient facility.

Caldwell said hourly welfare checks on the patient were inconsistent and sometimes incomplete.

"I consider that cumulatively these shortcomings represent a service delivery failure, for which ultimately Te Whatu Ora Counties Manukau is responsible."

She recommended the mental health service and Te Whatu Ora Counties Manukau audit the health service to create a cohesive care plan between the organisations.

Caldwell also recommended the mental health service consider developing policy and procedures to support staff in managing patients with known drug or alcohol misuse and provide training to staff on strategies to support effective management of certain disorders.

She noted that both the community mental health service and Te Whatu Ora Counties Manukau had made changes following the patient's death.

Both organisations were asked to formally apologise to the woman's family.

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: free counselling for 5 to 19 years old, online chat 11am-10.30pm 7days/week or free phone 0800 WHATSUP / 0800 9428 787 11am-11pm Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi and English.

Rural Support Trust Helpline: 0800 787 254

Healthline: 0800 611 116

Rainbow Youth: (09) 376 4155

OUTLine: 0800 688 5463 (6pm-9pm)

If it is an emergency and you feel like you or someone else is at risk, call 111.