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Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Dr Vanessa Caldwell has today released a report finding Counties Manukau District Health Board (CMDHB) (now Te Whatu Ora Counties Manukau) and a Community Mental Health Service (CMHS)[1] breached the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a woman in her twenties.
The woman had a history of self-harming and life-threatening behaviour and was admitted to the CMHS acute respite facility for a seven-day stay, which was later extended. During her stay, the woman struggled with low mood and suicidal thoughts and sadly was later found deceased in her room.
The agreement between CMDHB and the CMHS stated that CMDHB was responsible for the clinical treatment of clients. The crisis management plan developed by clinical staff at CMDHB, along with other information gathered by the clinical team, including possible withdrawal management support, should have been appropriately and consistently documented to assist the Peer Support Specialists at CMHS to appropriately manage the woman’s care.
Dr Caldwell found the failure by CHDHB to ensure up-to-date and accurate information was recorded in the woman’s care plans represented a failure to ensure cooperation and coordination of care and breached Right 4(5) of the Code.
Dr Caldwell also identified shortcomings in the clinical care provided to the woman. This included the lack of a face-to-face psychiatric assessment prior to making the decision for her to stay at CMHS, as opposed to her moving to a secure in-patient facility, and failure of the clinical team to appropriately consult at key points in her care.
Dr Caldwell said, “I consider that cumulatively these shortcomings represent a service delivery failure, for which ultimately Te Whatu Ora Counties Manukau is responsible.” Accordingly, Dr Caldwell found Te Whatu Ora Counties Manukau breached Right 4(1) for failing to provide services with reasonable care and skill.
Dr Caldwell was critical of CMHS’ process of conducting wellbeing checks. She noted the inconsistent and sometimes incomplete approach by staff to hourly observations and the lack of robust recording of the checks.
Dr Caldwell made several recommendations for Te Whatu Ora Counties Manukau, including that they conduct an audit to ensure that residents at the CMHS each have a single collaborative care plan developed which is current and well understood by care teams and that they provide suitably trained staff to undertake on-site reviews and improve communication between clinical leads and respite staff.
Her recommendations for CMHS included that they consider developing policy and procedures to support staff in effective management of patients with known drug or alcohol misuse and provide training to staff on strategies to support effective management of certain disorders.
Both CMDHB and CMHS have made changes to their processes following these events.
[1] CMHS was contracted by CMDHB Mental Health Services (MHS). It provides 24/7 support for guests with an acute episode of mental illness, as an alternative to inpatient admission.