Now her father is calling for changes to the Mental Health Act to ensure patients seen at emergency departments for attempted suicides are sectioned - that is put into compulsory treatment.
“I want my daughter to be able to change legislation so her life means something, so she can save other people,” the man said.
However, the Government is considering minimising, rather than strengthening, the power to impose compulsory treatment.
The Star has agreed not to name the Christchurch woman and her family in order to protect the privacy of her two children.
The Canterbury District Health Board undertook a serious event review to examine its care delivery leading up to the woman’s death at her home last year.
The father has released the review to The Star as he alleges "professional negligence and system failures".
He has lodged a complaint with the Health and Disability Commissioner, who is investigating, and considering the review’s findings. The death is also the subject of a coronial inquiry.
The review recommended the board review its suicide risk classification guidelines in order to ensure clarity of use and implementation.
At Christchurch Hospital on January 19, the woman, who was diagnosed as bipolar two years earlier, was classified as high risk and monitored by security.
She had been taken there by ambulance about 1am after phoning emergency services and reporting having drunk alcohol and taken more than 200 prescription tablets.
Later that same day, a CDHB crisis team, which was two Specialist Mental Health Service crisis resolution social workers, undertook a home assessment and assessed her as low risk.
The hospital had discharged the woman about 8am. She had refused a psychiatric assessment and walked out. She had denied trying to harm herself and toxicology results suggested she had not taken an overdose.
The review also identified a care delivery problem. This was that the service did not follow protocol by failing to engage a Pukenga Atawha to attend the home assessment. The woman was Maori and not sending the specialist cultural practitioner had deviated beyond safe limits of practice.
Among the review’s findings was that the service’s crisis resolution was “under-resourced and busy” at the time of her admission, necessitating prioritising of patients. It would have been preferable for the woman to be assessed at the hospital, but she had been followed up after discharge and received a “comprehensive assessment” at home.
Her father wants the crisis team and managers to resign as he alleges they did not listen to the family’s appeals to section the woman.
He alleges it was clear she met the threshold for sectioning, which was having a mental disorder that posed a serious danger to her safety.
CDHB acting chief medical officer Dr Richard French said he could not comment on the care provided to individuals.
Minister of Health Andrew Little said he also could not comment on the specifics of individual cases.
Submissions have recently opened on the repeal and replacement of the Mental Health (Compulsory Assessment and Treatment) Act 1992. A recent government inquiry recommended reforms minimise compulsory or coercive treatment. Submissions close January 22.
Little said there had been concern about the compulsory nature of some people’s admission to facilities.
“And I know that there are some people who are saying that the ability to do that under the law should be removed.
The revised Mental Health Act won’t do that, but it will ensure people’s rights are protected,” Little said.
Desperate pleas for assistance
Interviews with family members of a woman who died of suspected suicide after leaving Christchurch Hospital reveal their desperation in trying to save her.
The interviews are documented in the CDHB’s serious event review.
Her father and cousin said the 28-year-old put up disturbing posts on Facebook on January 17, 2020, such as “I’ve had enough,” and “Watch this space – going out in a blaze of fire.”
The following day she dropped her young children off to her former partner’s house after an outing, and for the first time dropped her dog off as well.
“She wouldn’t give that dog up for anyone,” the cousin said.
The former partner said he was so concerned about this that he contacted police, who looked for the woman for hours. He “pleaded with the police to find her, take her to the hospital and make her stay”.
The cousin said she located the woman in hospital about 1am on January 19 after a reported overdose. The first thing the woman did after getting home later that morning was take pills downed with bourbon.
Three of the woman’s family members – grandmother, uncle and cousin – went to her house later that day. They were there when a crisis team, that is two crisis resolution social workers from the CDHB’s Specialist Mental Health Service, arrived on an unannounced “cold call” visit, prompted by a phone call from the woman’s mother.
The cousin said the family wanted the woman to be admitted, under the Mental Health Act if necessary, but the team “had thrown them under a bus” by telling the woman this.
The cousin said the woman would have been safer and felt more supported without the interaction of the crisis team.
When family members left the premises, they understood the two social workers would check on her later that night with a phone call and follow-up visit if the phone was unanswered. However, there was no follow-up visit when two phone calls, about 9pm, went unanswered.
Family members believe the woman died by suicide that evening. She was found deceased by police doing a welfare check the following day.
