Canterbury's Mental Health Services inquiry findings 'really concerning', psychiatrist says

A forensic psychiatrist with nearly 30 years experience says unless an inquiry into Canterbury's Mental Health Services prompts real change there will be "more adverse incidents".

The inquiry, by Director of Mental Health Dr John Crawshaw, found "significant" problems in the service's governance, care model and resourcing.

Dr Crawshaw began his inquiry under section 99 of the Mental Health Act in June 2022, after Hillmorton forensic mental health patient Zakariye Mohamed Hussein murdered Laisa Waka Tunidau as she walked home from work.

Hussein was on community leave at the time of the killing.

The findings, released on Tuesday, included "critical staff shortages", staffing vacancies affecting admissions and discharge processes, a "siloed culture and care model", concerns about the service's governance and delayed resourcing decisions at the regional governance level.

The final report, released three years after it began, has 18 recommendations aimed at addressing the key issues.

Dr Erik Monasterio, a forensic psychiatrist with nearly 30 years experience, worked at the then-Canterbury District Health Board (CDHB) for 25 years. He was the Clinical Director and Director of Area Mental Health Services for the Canterbury Forensic Service between 2015 and 2021.

Speaking to RNZ, Dr Monasterio said his first impression of the report was how the recommendations were going to be "implemented and opreationalised" in a way that would lead to "improvement in functioning and a reassurance around patient safety and reasonable standards being met".

Dr Monasterio said the inquiry's findings were "really concerning".

Issues around governance identified in the report were "at the core" of difficulties that had arisen, he said.

He said he wrote a letter in late 2016 which was co-signed by other clinical directors of the DHB's mental health services addressing "likely implications" of the change in leadership and governance structure that had been identified in the report.

"I forewarned that this change in leadership structure was going to undermine the viability of the services and likely lead to adverse outcomes.

"So it's very, very frustrating that those concerns were largely ignored. And some of the issues that have arisen, a significant component of the issues that have arisen, are as a consequence of that change in leadership and governance structure."

Asked how unsafe Canterbury's Mental Health Services were in 2022, Dr Monasterio said a lot of very experienced staff had left.

"The knowledge at every level of the institution was significantly watered down.

"The processes had become watered down. So in the absence of good processes and good leadership, you just don't know what you don't know. But you know you're sitting in a situation which is potentially very risky."

Dr Monasterio said he left his role over concerns he had about the "viability of the service".

"To the extent that I felt I couldn't remain in the leadership position because I felt that there were acute risks, both to staff and patients and the community, and I could not enact a positive change from within the institution and as a Forensic Service at the highest level of seniority that I could achieve."

He said Dr Crawshaw's report "paints a grim picture".

"The issues that are identified therein, unless people can convincingly show that they have an initiative and a plan to change that, then I think it'll just continue to get worse," he said.

"Unless you get this right there's going to be more adverse incidents. I don't think there's any doubt about that."

Consultant forensic psychiatrist Associate Professor James Foulds, who worked at Hillmorton for seven years until 2023, told RNZ he felt the report was a "fair summary" of the problems in the mental health system.

"I feel sad for the people who have been affected by the poor state of mental health services in Christchurch - not just the families of the two people who were murdered but also the many people with serious mental illness who haven't been able to get an acceptable level of care, and the health staff who have suffered from working in this environment."

He said there needed to be "accountability" from senior mental health service management in Canterbury.

"Some of the senior managers who were present at the time have already moved on, but there needs to be a change in the culture of the organisation and that starts at the top."

Dr Monasterio agreed.

"Unless you change that culture, nothing's going to change."

'Critical' staff shortages

Dr Crawshaw said the "most significant and prevailing issue" concerned staffing in the clinical areas, especially the adult inpatient, community and forensic services.

"In the inpatient areas, there were daily issues in ensuring minimum safe staffing levels."

The divisional leadership team had "significant concerns" about the number of staff vacancies and the "relatively junior nature" of the clinical staff in some areas.

There were "critical shortages" of staff in many areas of the service, particularly inpatient units.

"Clinicians frequently used the phrase 'on numbers', referring to being deployed to an inpatient unit to bring up the numbers of staff on a roster to a perceived safe capacity.

"The inspection team heard concerns that people were working overtime and double shifts, to meet the 'on numbers' expectation. While the magnitude of the issue was unclear, it was raised repeatedly by staff in interviews. Some staff stated that they no longer wished to do overtime and double shifts due to the level of personal stress and strain it caused them."

Staff 'afraid to come to work'

In relation to nursing staff, Canterbury, like other services across the country, had a challenge with a "missing middle" - nurses who were "competent and experienced but still have a long career in front of them".

When the inspection was carried out there was a group of staff nearing retirement. They appeared "fatigued and were possibly experiencing burnout".

Some of the new graduates had been placed in "unsafe situations".

"For example, a newly graduated registered nurse spoke of arriving for a shift at the forensic mental health inpatient unit and being told that they would be the shift leader, a task they felt wholly unprepared for."

Some nursing staff were "afraid to come to work" with an "unacceptably high rate" of assaults on nursing staff by patients.

"Staff reports of experiencing the clinical environment as unsafe were particularly prevalent in forensic services. There, staff described how a number of senior staff had recently left, particularly from the acute medium secure unit.

"This had left both a gap in staff numbers and a gap in expertise. Some staff appeared to be distressed by and angry at the situation; particularly those working in the acute medium secure forensic ward."

'Significant failings'

Health New Zealand (HNZ) national director of mental health and addictions Phil Grady acknowledged the "significant failings" identified in the report. HNZ was "committed" to implementing the recommendations to "prevent the tragic events of 2022 and 2024 from happening again".

"We recognise the loss and grief these families have and continue to experience and express our sincere condolences to them. We are deeply sorry for the failings in our systems.

"We have reached out to these families to apologise and discuss Dr Crawshaw's report, and will remain in contact, if that is their choice, to update them on progress to implement actions from the report."

HNZ accepted all of Dr Crawshaw's findings and had an action plan in place to implement the recommendations, which focused on the underlying issues related to governance, the care model, and resourcing.

"We are focused on continuing to provide senior leadership oversight of planning for the service, building a framework, and ensuring there is sufficient staff with the right level of training and experience to safely and effectively deliver services."

Grady said there had been "demonstrable progress" on key recommendations including establishing a clinical governance framework and increasing clinical staffing by 11 percent since 2022. Clinical decision making on patient leave was "consistent with policies" and there were weekly audits of compliance in place.

"There are clear pathways both within the service and nationally within Health New Zealand to escalate and manage risk."

'We are taking action'

Mental Health Minister Matt Doocey said in a statement Waka Tunidau's death was a "tragedy no family in New Zealand should ever have to experience".

"The release of this report today is an important moment. It shines a light on the long-standing failings in Canterbury's mental health services, failings I've been assured, there is a robust plan in place to address.

"I have been upfront that we must do better to improve the mental health system and improve outcomes, this has been my top priority from day one."

He said the government inherited a "long-standing fragmented and underperforming mental health system".

"And this report underscores the scale of the challenges we have been left with and continue to face."

Doocey said public and patient safety "must always come first".

"I have made it clear to Health New Zealand that the issues identified in this report must be addressed urgently, and that progress must be visible and ongoing.

"We are taking action. I have prioritised committing additional funding for forensic services, strengthening regional accountability, and growing the mental health workforce. Because every New Zealander should be able to get the support they need, when and where they need it, and those around them should have faith that they will be properly looked after while in care."

Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.