The suicide-risk of a mental health patient who died after falling from a bridge on to a motorway was not communicated adequately to her carers before her death, a coroner's court has found.
Juanita Michelle Amataiti, 32, died in Wellington Hospital's intensive care unit on July 6, 2006, following a fall from Mungavin Bridge in Porirua.
At an inquest into her death, a Wellington court was told Mrs Amataiti had struggled with mental health problems since she was 17, including a bipolar disorder, self-harming behaviour, an eating disorder, post-traumatic stress disorder and alcohol and cannabis abuse.
On June 24, Mrs Amataiti was taken to Kenepuru Hospital for an assessment after she became more depressed and her estranged husband became concerned about her and her ability to care for the pair's two-year-old daughter.
She was later admitted to a recovery house in Whitby operated by Pathways.
While being taken to the Regional Acute Day Service at the hospital on June 29, Mrs Amataiti, who was seated in the back seat of the car, undid her seatbelt as the car drove over the Mungavin Avenue overbridge, opened her car door and ran to the bridge barrier.
She climbed between the guard rail and top rail and jumped into the southbound lane of traffic on the motorway below.
Giving evidence at the inquest, Pathways general manager Lyndsay Fortune said Mrs Amataiti was treated as a low-risk client during her stay at the recovery house as Pathways had not been advised that she was at risk of suicide attempts.
When Mrs Amataiti was taken to the hospital, her husband described several previous suicide attempts by his wife. The psychiatric registrar noted Mrs Amataiti's suicidal ideation but did not include a note of it in her treatment plan.
If there had been any doubt about Mrs Amataiti's safety being transported to the hospital by car other arrangements would have been made, Ms Fortune said.
Pathways had a policy of keeping doors unlocked whilst transporting people "because locking doors can constitute an unlawful restraint", she said.
The court responded, saying it was common practice to lock the doors of vehicles for safety reasons, adding that kiddie locks were a common safety feature in modern cars.
However, while the court found locking the vehicle's doors would have prevented Mrs Amataiti's death, there was no adequate risk assessment or management plan to suggest she was at risk of suicide.
A sentinel event review found the issue of Mrs Amataiti's suicidal ideation should have been highlighted to Pathways, and, among its recommendations, advised the DHB to adopt better documentation procedures for such issues.
The DHB had taken significant steps to implement the recommendations made by the sentinel review team and the court, commenting that the recommendations were well thought out and sensible, made no recommendations of its own.
