Source: MIL-OSI Submissions
Source: Office of the Ombudsman
The Chief Ombudsman has identified significant gaps in the Ministry of Health’s collection and use of information about the deaths of people with intellectual disabilities receiving full-time residential support.
The report Off the record examines the data collected by the Ministry about the deaths of 108 people over a two-and-a-half year period, with a particular focus on a sample of 41 deaths.
“I began this investigation after being approached by people from the health and disability sector with concerns about a lack of information, follow up and reporting, especially when there was a sudden or unexpected death”, Peter Boshier says.
“The death of a loved one is always difficult, particularly where there may be a sense of unanswered questions. It’s important that there is adequate oversight of what happened when a family or whānau loses someone who was receiving residential support,” Mr Boshier says.
The investigation found that the Ministry’s systems were not adequate or robust; information collected was not complete, accurate, or sufficient; and there was no evidence of it being used to make improvements in practice.
Mr Boshier says the Ministry’s record keeping deficiencies were brought into sharp focus by the problems his investigation teams had obtaining relevant information.
“My investigation led to the Ministry service responsible for overseeing residential services identifying 30 deaths during the period under investigation that it was previously unaware of”, he says. “This was despite the information being held in other parts of the Ministry.”
“People with intellectual disabilities are amongst the most marginalised members of society”, Mr Boshier says. “Their overall health is poorer compared to people without intellectual disabilities, and they have a significantly lower life expectancy.”
“The Ministry of Health funds residential support services. It is also responsible for monitoring the system, quality control, and leading improvements that support people to live longer and healthier lives.
“I fail to see how it can meet these responsibilities or measure its own performance without good data and accurate record keeping”, Mr Boshier says.
Mr Boshier says the Ministry has already made substantial improvements, including introducing a Standard Operating Procedure for the reporting of deaths.
“I have made 10 recommendations, which aim to ensure the new approach is fully effective and sustainable, and which look to additional opportunities for improvement. These include a recommendation that the Ministry establishes an audit process to ensure relevant information is being shared, and records are up to standard. I have also recommended that the Ministry takes steps to ensure an appropriate level of review following a death.”
“The Ministry has acknowledged the need for further improvement, and stated its commitment to implementing my recommendations. I will monitor progress closely, and am encouraged by the way in which the Ministry has engaged with my investigation”, he says.