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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a district health board (DHB) and a Crisis Assessment and Treatment Team (CATT) mental health nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the assessment and treatment of a man with acute mental health needs.
The man became unwell while working in a remote location, and was taken to be seen by the DHB’s Acute Care Team (ACT). He was assessed by two mental health nurses, and then returned home to his family in another DHB region.
The man’s mother was concerned about his wellbeing and took him to the closest emergency department (ED) that evening, and ED clinicians referred him to CATT. This team was based in another town, and the CATT mental health nurse spoke with the man’s mother on the phone, but did not speak with the man directly. A plan was made for the man to return home with a sleeping tablet and to be seen in person by CATT in the morning.
Tragically, early the next morning, the man died of suspected suicide.
Mental Health Commissioner Kevin Allan considered that the ACT clinicians did not ensure that the man received an adequate mental health assessment, and that the subsequent management plan was inadequate. In Mr Allan’s view, the DHB was responsible for these failures.
“The DHB had overall responsibility for the services that were provided to [the man] when he presented to ACT for acute mental health care,” said Mr Allan. “In my view, there were several failures by the DHB staff in providing care to [the man]. As a result of these failures, an opportunity was lost to identify the extent of [the man’s] illness and access appropriate treatment, and [the man] did not receive continuity of services.”
Mr Allan was also critical that the CATT mental health nurse did not seek to assess the man’s mental health status when she first spoke to his mother; did not assess or speak with the man at any stage; and developed her safety plan in the absence of an adequate assessment of the man’s mental health, in the context of a known suicide risk. The nurse also did not consider herself responsible for the safety plan she developed, and she dismissed concerns raised by a colleague.
Mr Allan recommended that the DHB provide HDC with an update on the results of its review of both its documentation and the training and development needs of the clinicians who work with the ACT; provide training to ACT staff on mental health assessments of out-of-area consumers who are unknown to the service; and provide an apology to the family with input from the nurses involved. He also recommended that the other DHB undertake a review of the effectiveness of its structural changes to CATT; review its policy on suicidal presentations to ED; use HDC’s report as a basis for training and reflection for CATT staff; and apologise to the man’s family.
Mr Allan recommended that the CATT mental health nurse provide a reflective statement on the changes to her practice as a result of these events; provide evidence of her training on the assessment, management, and care of a consumer who presents with suicidal ideation; and provide an apology to the family.
He also recommended that the Nursing Council of New Zealand consider whether a review of the registered nurse’s competency, fitness to practise, and/or conduct is warranted.
The full report for case 18HDC00301 can be found on the HDC website.