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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Mental Health Commissioner Kevin Allan today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights for failing to adequately plan treatment for a man who later died by apparent suicide.
The man had a history of deliberate self-harm and previous suicide attempts, and significant previous involvement with the DHB’s mental health service. Following an attempt to self-harm, he was admitted to an open ward of the DHB’s inpatient mental health unit. After approximately a week, the possibility of overnight leave was discussed with the man. He went on day leave but this did not go well. The following day, he went missing from the ward, and was found to have died by apparent suicide.
Mr Allan was critical that despite the man’s established history of mental illness and suicide attempts, the DHB failed to assess him and his level of risk adequately, record key information about him, and formulate a diagnosis. This was compounded by the DHB’s lack of an easily accessible electronic mental health record.
“[These] failures meant that there was a lack of an easily identifiable, current and comprehensive treatment plan,” said Mr Allan.
“The widespread failure of [the DHB’s] medical and nursing staff to document discussions, decision-making, history, and treatment plans accurately during the period considered points to a culture of non-compliance with professional standards at [the DHB] at that time.”
Mr Allan recommended that the DHB make changes to ensure a comprehensive formulation and treatment plan is developed with patients, and audit compliance with its changes. He also recommended that the DHB apologise to the man’s family.
The full report for case 17HDC01544 is available on the HDC website.