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A woman with long-term psychiatric issues who injured a stranger while she was undergoing community-based treatment received inadequate care from the Southern District Health Board, the Health and Disability Commissioner has found.
While the patient, Ms A, had an extensive history of mental health problems and there were several mitigating factors, on balance systemic issues at the SDHB meant the organisation was accountable for lapses in her care, mental health commissioner Kevin Allan said.
"This decision highlights the importance of having a broader overall care plan for any consumer, which will require timely psychiatric oversight and should always take account of cultural needs,'' Mr Allan said.
The SDHB said it had "sincerely and unreservedly apologised'' to Ms A and her family and had already made changes to implement the HDC's recommendations.
The HDC report on Ms A's case said she had accessed mental health services since the mid-1990s for bipolar affective disorder.
In February 2015, Ms A's mother called the SDHB's mental health emergency team and asked for her daughter to be admitted under the Mental Health Act.
A psychiatrist, Dr B, assessed the woman and decided she should instead be managed by the community mental health team.
In March Ms A's mother confiscated hunting knives from her daughter, and told clinicians her daughter's highs and lows were more extreme.
Shortly after, Ms A was taken into police custody after harming a woman unknown to her.
Mr Allan said Dr B's documentation of the case was inadequate, and criticised the doctor for having failed to discuss Ms A's mental health with her mother after the February assessment.
"In reviewing Ms A's care, my fundamental concern is the lack of an adequate care plan, contributed to by the lack of psychiatric review over a protracted time,'' Mr Allan said.
"This is aptly summarised by [independent adviser Prof Wayne Miles] Prof Miles' comment that the care offered `seemed to be of wait-and-see, rather than a careful, structured plan that sought to create engagement and the gathering of sufficient information to know the depth and severity of the illness effect'.''
SDHB chief executive Chris Fleming said the DHB failed to provide Ms A and her family with the standards of care and support they required, and accepted without qualification the commissioner's opinion.
"We are committed to ongoing service improvements, and will continue to work to prevent recurrence of any similar event in the future.''
A substantial independent review of Maori mental health services had been carried out, and services, processes, policies and standards had been improved, he said.
"The service has also commenced a programme of work to implement the recommendations of the serious adverse event review.''