Two of an estimated 5000 people who used Otago District Health Board mental health services in 2007 went on to commit unspecified serious crimes, a report released recently shows.
Most of the 19 reports of events the board made to the director of mental health that year, however, involved suicide or apparent suicide of patients.
Board clinical director for mental health and intellectual disability services Dr James Knight said he was unable to elaborate on basic information on individual cases given in the report issued by the country's 21 boards because of issues of confidentiality.
Reviews of the various events had not identified gross errors or major process difficulties and recommendations made were more "fine tuning", he said.
"We haven't had the sorts of events where we've seen major errors in treatment delivery."
One of the serious crime cases involved a patient absent without leave, a situation which the review of the case found was neither preventable or predictable and represented a significant increase in seriousness from previous offending by the patient.
No recommendations regarding clinical care were made as a result of that review.
In the other case, the patient had been assessed and discharged by the mental health service.
The review found that assessments, documentation and communication were all appropriate and management at each stage of contact with the service appeared to have been carefully considered and appropriate in the circumstances.
The review recommended that the board should at some stage liaise with the police and the corrections department to share information about their reviews.
Of the 11 cases listed as suicide or apparent suicide, two involved inpatients on leave.
In one of the cases, no recommendations were made by the review team, which found the plan to put the patient on overnight leave was appropriately cautious, well reasoned and with clear plans in place to follow the patient's progress.
In the other case, while it was felt care was appropriate, the review raised concerns about the delay in the emergency department notifying the psychiatric service about the patient.
As a result, it was recommended that the rule of waiting for a patient to be medically cleared before being reviewed by psychiatric staff should be changed.
That case also raised concerns about staff misunderstanding of some of the Mental Health Act, which has been rectified by extra training.
Lack of effective cover when some staff are on leave was another concern which has been reviewed.
The family in this case did not feel it had adequate support over the years and the review found communication within the ward and with the family could have been improved, the report stated Recommendations in another case involving the suicide of an outpatient included consideration of the benefits of referring families to support organisations and providing education to the wider family.
Dr Knight said staff worked really hard on providing family support and ways of improving communication.
This included involving family in the investigation of reportable events.
Mental health and community services group manager Elaine Chisnall said it was not possible to compare one year's figures with another because there was an increased awareness among staff about event reporting.
Staff were keen to look at these tragic events to see if there were any improvements to be made.
People of Otago could be confident the services being provided by the board were "good safe services".
The district health boards have also cautioned against making comparisons between areas because different boards interpreted the reporting requirements differently and some areas provided more services than others.
