The Southern District Health Board and a psychiatrist have been sternly criticised by the Mental Health Commissioner after a patient died on hospital grounds in an apparent suicide.
The man, who had a history of self-harm and suicide attempts, died in 2017.
Commissioner Kevin Allan said despite the man’s well-established medical history, the SDHB failed to assess him and his level of risk adequately, record key information about him, and formulate a diagnosis.
"[These] failures meant that there was a lack of an easily identifiable, current and comprehensive treatment plan.
"The widespread failure of the DHB’s medical and nursing staff to document discussions, decision-making, history, and treatment plans accurately during the period considered points to a culture of non-compliance with professional standards at the DHB at that time."
The man was taken to the emergency department following a suicide attempt, and twice more tried to take his life the day before being transferred to another hospital – prompted by fears of being moved to transferring from a secure unit to an open one
When the man arrived at the second hospital he was placed in an open ward, but was not seen by a psychiatrist until later that day.
The doctor, who knew the man due to five previous admissions to the hospital, opted to keep him in the open ward.
The commissioner said there was nothing in the psychiatrist’s notes to explain why he later recommended the man’s status as a compulsory patient should end and that he be given overnight leave.
After a day leave, which did not go well, the man was noted as missing at 10.30am the following morning.
He was found dead at 9am the next day but the SDHB did not tell the man’s family as they believed the police would do so.
The family were informed at 3pm, when they contacted police to volunteer their help to find the man.
The SDHB’s review of the case resulted in the introduction of a self-harm risk analysis tool, and it had also sought to ensure a standardised approach was taken to complex cases.
However, the commissioner said the SDHB failed to provide adequate treatment to a man who had twice tried to kill himself before being transferred to a new hospital.
No structured psychiatric history or current mental status formulation and diagnosis were documented, and no electronic, easily accessible mental health record was available.
The commissioner also criticised the psychiatrist for poor record keeping, and notified the Medical Council of his decision.
SDHB chief medical officer Dr Nigel Millar apologised to the family.
Where to get help
• Need to talk? Free call or text 1737 any time for support from a trained counsellor
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• Lifeline, phone 0800 543 354, or text HELP to 4357.
• In an emergency, or if you feel you or someone else is at risk, phone 111.
