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The Southern District Health Board and a psychiatrist breached the patients’ code of rights in their care of a woman who died, the Mental Health Commissioner has found.
In his written decision, Kevin Allan said the woman had experienced a decline in her mental health after an accident.
Aged in her 60s, the woman referred herself to the mental health service.
The psychiatrist diagnosed a major depressive episode. A nurse was appointed as her key worker. Two months later, she was admitted to an inpatient ward after a self-harm incident.
After she refused regular antidepressant medication, and denied suicidal intent, she was discharged after nearly a week.
She was readmitted after a further incident of self-harm, and discharged with a follow-up plan.
She died a few days after a review by the psychiatrist.
Her treatment plan stipulated daily key-worker contact, but that did not happen because of confusion about the arrangements.
Mr Allan said the psychiatrist failed to provide services of an appropriate standard.
The decision to discharge the woman the second time was inappropriate.
There was inadequate risk assessment, and a lack of documentation regarding the psychiatrist’s decision not to use a compulsory treatment order.
The nurse attracted "adverse comment" in the finding for poor documentation and communication.
Neither the psychiatrist nor the nurse are now practising.
In the event the psychiatrist returned to practice, Mr Allan suggested a competence review could be needed.
If the nurse practised again, she ought to undertake a documentation course, Mr Allan said.
Mr Allan recommended that the Southern DHB develop protocols for improving care co-ordination in such cases.
The DHB and the psychiatrist were told to apologise to the woman’s husband.
Yesterday, the board’s communications team released a statement from mental health medical director Dr Brad Strong.
"We extend our sincere condolences to the family of this patient for their loss, and apologise for the aspects of her care by the mental health service that were less than the best standard.
"We have already implemented the recommendations made by the Health and Disability Commissioner," Dr Strong’s statement said.