Health Investigations – Psychiatrist fails to communicate appropriately with patients in three separate cases

In the first case, Dr Caldwell considered that the language used by the psychiatrist in his written communication was inappropriately derogatory, reflected his personal views about a patient, and was very unlikely to promote a trusting relationship between them. In addition, Dr Caldwell had concerns about several aspects of the psychiatrist’s management of the patient’s medication regimen over a lengthy period while the patient was subject to compulsory treatment.

In the second case, Dr Caldwell found that the psychiatrist used, in both his oral and written communications, inappropriate, non-therapeutic, and disrespectful language towards and about the patient. The psychiatrist also allowed his personal views to inappropriately affect his interactions with the patient.

In the third case, Dr Caldwell found that the psychiatrist failed to recognise the distress of a patient and his mother, and to listen to and be receptive to their concerns in an empathetic and respectful way. He also used disparaging and inappropriate language in his written communication.

“I find it very troubling that these three cases present consistent themes of the psychiatrist not treating people with respect, allowing his personal views (which often were negative and disparaging) to affect the care he provided, and using inappropriate language that was, at worst, likely to distress, and certainly unlikely to foster a trusting and therapeutic doctor-patient relationship. These themes persisted across five years,” said Dr Caldwell.

“I do not accept that the language and words he used to describe his patients was just blunt, factual, or to the point. On the contrary, particularly in his written referrals to medical colleagues, his words were subjective, his own opinion, unprofessional, and derogatory.”

With regards to the DHB, the Deputy Commissioner considered all District Health Boards to be responsible for the operation of the clinical services they provide. In addition they have responsibility for the actions of their staff, including to ensure that all consumers are receiving care from there staff are treated with respect.

“In my opinion empathetic and respectful communication is vital to effective psychiatric care. I am concerned and disappointed that the DHB failed to support the psychiatrist to communicate appropriately. Despite the issue being raised with the DHB previously, the psychiatrist’s inappropriate language and lack of empathy towards and about patients persisted. As a result three different patients have had upsetting interactions, often when they were at their most vulnerable or distressed, and needed and deserved supportive and respectful care,” said Dr Caldwell.

Dr Caldwell also had a number of concerns about the clinical care that the first patient received, for which she considered the DHB had overall responsibility.

• attend further training, provided by people with lived experience of mental distress, on therapeutic communication, establishing trust and rapport with mental health patients, treatment of Bi-Polar Disorder, and how to manage risk of countertransference;
• provide a reflective statement to HDC about these cases; and
• provide formal separate written apologies to each of the three patients and their whānau.

The Deputy Commissioner recommended that the DHB:

• audit a random selection of 20 pieces of clinical documentation written by the psychiatrist to assess the appropriateness and standard of the content;
• provide details of the feedback given by DHB staff who observed the psychiatrist in three consultations, and details of any further training or support for the psychiatrist identified as necessary;
• consider adopting a new guideline for monitoring patients on antipsychotic medications;
• consider adopting a new form, to be incorporated into multidisciplinary team meeting notes, to prompt staff when repeat tests or reviews are due; consider adopting a form to request and reply to applications for a second opinion for patients who are subject to the Mental Health (Compulsory Assessment and Treatment) Act 1992; and
• provide formal separate written apologies to each of the three patients and their whānau.