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Auckland's Middlemore Hospital has admitted that it "failed" musician Peter Gutteridge, who died in the hospital's Tiaho Mai mental health unit.
Deputy Chief Coroner Brandt Shortland has found that Gutteridge's death on September 15 in 2014, was self-inflicted.
Gutteridge was a founding member of late 1970s and early 1980s Dunedin bands The Chills and The Clean, and was described by Flying Nun, the label that released much of his music, as "a true hero of New Zealand music".
Gutteridge, who was 53, was admitted to Tiaho Mai under the Mental Health (Compulsory Assessment and Treatment) Act after arriving at Auckland Airport in an "agitated and confused" state on September 12, 2014 after visiting the United States.
The hospital placed him on a system requiring observations every 15 minutes, and the coroner's report records that this regime was followed through the night before he died.
Two friends who visited him over the weekend told a registered nurse that they were concerned for his safety because he said, "I don't know if I'm going to last very long," and he was worried that he had not made a will.
This information was passed on to nurses on the overnight shift.
But Counties Manukau District Health Board clinical director of mental health and addiction services Dr Peter Watson told the inquest that his service "failed Mr Gutteridge".
An internal review found "shortfalls in a number of areas" including:
• "Staff competency in recognition, assessment and the treatment of acute opioid dependence detox was lacking."
• "There were issues with clinical leadership and communication across the continuum of care with after-hours medical and nursing teams."
• "The different on-call clinical leadership structure at weekends affected staff communication and collaboration issues."
• "There were environmental risk factors within Tiaho Mai."
• "There was a failure to organise a follow-up medical review, as requested by the admitting consultant psychiatrist."
• "Clinical notes were at times poor and the checklist for the generic 15-minute observations was completed inconsistently."
The current $57 million rebuild of the Tiaho Mai unit includes design changes aimed at preventing future deaths, but construction has been delayed by this month's financial collapse of the builder, Ebert Construction.
An external review by Dr Sue Mackersey of the Bay of Plenty District Health Board found that Gutteridge's "acute and changing needs were not formally reassessed during the two and a half days following his admission".
Mackersey found that the initial assessment "was not formulated in a way that directed monitoring and treatment of withdrawal" from opiate drugs, and that staff failed to consult with Gutteridge's next of kin, his sister Elizabeth Gutteridge in Dunedin, after she rang the unit twice on the day he was admitted.
Mackersey recommended changes including having acute patients reviewed by a registrar and a psychiatrist over a weekend and liaising with family members.
"Dr Watson acknowledged that Elizabeth Gutteridge was Mr Gutteridge's next of kin and their quality of information and communication was woeful," the coroner found.
An inquiry by the Health and Disability Commissioner also found failings in the hospital's care of Gutteridge and recommended changes.
"As a direct result of Mr Gutteridge's unfortunate death, the CMDHB Mental Health Services (In[patient Services) underwent a major restructure," the coroner said.
He said a senior doctor was now rostered to work on weekends and holidays, guidelines on internal staff handovers had been improved, and a new adult inpatient unit was being built with safer design features.
WHERE TO GET HELP
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
OR IF YOU NEED TO TALK TO SOMEONE ELSE:
• LIFELINE: 0800 543 354 (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633
• NEED TO TALK? Free call or text 1737 (available 24/7)
• KIDSLINE: 0800 543 754 (available 24/7)
• WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757