Ashburn Hall faulted over woman's treatment

The woman was treated at Dunedin's Ashburn Hall for two years. Photo: ODT files
The woman was treated at Dunedin's Ashburn Hall for two years. Photo: ODT files
A Dunedin mental health and addiction clinic has been found in breach of conduct after a vulnerable woman was left without the support needed, leading to a series of crises.

Deputy health and disability commissioner Dr Vanessa Caldwell found that Ashburn Hall Charitable Trust was in breach of the right to services of an appropriate standard, as outlined in the Code of Health and Disability Services Consumers’ Rights.

The complaint involved a young woman discharged from the clinic in 2018, where she was treated for more than two years.

The woman, aged in her twenties at the time of events, had a complex history of post traumatic stress disorder, depression, and significant self-harm and attempts at suicide.

Before transitioning back to her home town in September 2018, the clinic contacted the mental health and contact centre of Capital and Coast District Health Board, now Te Whatu Ora, with a referral for ongoing follow-up for the patient.

Ashburn Hall did not provide detail on the nature of the ongoing follow-up and expected Te Whatu Ora would assess the woman and address her clinical needs at that time, the report said.

The referral was sent on September 13, but treated as non-urgent by Te Whatu Ora and only delivered to community mental health staff on September 24, the day after the woman’s move.

No appointments with her had been made.

The woman stressed how important it was that she had support during the move.

‘‘When I start to go off the rails, I can be helped. If it is left too long, then there is little that anyone can do to help me,’’ she said.

The woman was discharged from the clinic and her care was transferred to Te Whatu Ora, but in the weeks to follow she failed to receive the support she expected and needed.

There were times she needed help and was unable to contact people for hours, the report said.

In the weeks following the transfer, the woman presented to the emergency department on several occasions, once after self-harming. She described her situation as ‘‘spinning out of control.’’

About two weeks after her discharge, she was admitted to a mental health recovery unit in a public hospital.

Dr Caldwell said the ‘‘inadequate discharge planning’’ caused a lack of clarity around the woman’s needs and expectations ‘‘at a time of increased vulnerability’’.

‘‘It is well known that the transition of care for mental health patients is a critical point and a period of risk because of the distress it can cause patients.

‘‘The clinic had the most in-depth and recent information on the consumer and should have taken more responsibility in her transfer to Te Whatu Ora’’.

She was also critical of Te Whatu Ora’s management of the referral, however this did not amount to a breach of code.

Dr Caldwell made many recommendations regarding the situation. These included written apologies to be provided to the consumer by the clinic and Te Whatu Ora, a review of transfer practice and post discharge reviews with the consumer and their family. 

Ashburn Hall Charitable Trust chairman Dr Clive Matthewson said it disagreed with the opinion, which was ‘‘a slight on the staff of Ashburn.’’

Dr Matthewson had sought at meeting with the commissioner to discuss the results of the report and to seek a constructive outcome.