The West Coast District Health Board has today been found in breach of the Code of Health and Disability Services Consumers' Rights for multiple failures in the man's care prior to his death.
Staff employed under the DHB did not check the man's room for risk points and when his condition escalated the appropriate care was not given nor was a plan put in place, a Health and Disability Commission (HDC) report revealed.
The man's sister, who cannot be named for privacy reasons, was the person who made the complaint. She said her family felt the service let her brother down.
"There was evidence that his care should have been escalated and there were more than sufficient indicators and time to have undertaken this, which likely would have saved his life.
"As a family it is expected that patients will be safe while in an inpatient environment, however as care was well below what is acceptable the outcome was the worst that anyone can imagine," she said in a statement included in the report.
In 2018, the man was a voluntary patient at a mental health inpatient unit under West Coast DHB.
He had a complex clinical background including a history of mental illness and was considered a moderate to high suicide risk, the HDC report said.
While at the facility, the man's condition escalated - he became agitated and refused his medication. During the night, he barricaded himself in his room and began slamming the door repeatedly.
For three hours the following morning, the man was left alone without any observation. He was found in his room following what was suspected to be an attempted suicide. He died four days later, the report said.
Mental Health Commissioner Kevin Allan, who led the investigation into the man's care, said he was concerned that following the man's admission, a nursing care plan was not developed and documentation was incomplete.
"In addition, several staff demonstrated a lack of critical thinking about the care that [the man] required overnight, and a lack of initiative in addressing his deteriorating condition," Allan said.
The commissioner also found the DHB did not ensure that the man's room was checked for risk points, failed to complete hourly observations, and did not escalate the man's care when his condition deteriorated.
Allan recommended the DHB finalise an escalation policy and provide evidence of training on this, audit staff and conduct a review of risk assessments.
He also recommended that the DHB apologise to the man's family for its breach. The DHB has since done so.
The DHB has also been referred to the Director of Proceedings, who can decide if any further action should be taken.
Where to get help:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.
