Commissioner exposes failures in mental health care after death of man who spoke of suicide

Warning: This story is about self-harm.

Poor record keeping and communication are at the root of mental health care failures for a man in his 60s who died at Wellington hospital after harming himself, according to a patient rights watchdog.

The man had been in the mental health system since his teens and was being treated by two psychiatrists and the crisis contact center in Greater Wellington, across Te Whatu Ora, Capital, Coast and Hutt Valley at the time of his death in 2019.

Prior to his death, the man’s parents expressed concern about their son’s deteriorating mental state, including suicidal ideation, agitation, insomnia, panic attacks and depression.

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On the day the man self-harmed, he was facing changes in his care which would have seen him transferred from a mental health service to community care.

This plan had been talked about for several months, including during a whnau meeting. The patient interpreted this as a withdrawal of his care, which worsened his distress.

But crisis mental health teams kept poor records of his increased contact with them during this time and failed to share important updates with his general practitioner, the Health and Disability Commissioner has found.

There was no evidence the man’s family doctor was told his psychiatrist had reduced antipsychotic medication at the patient’s request and no record of the psychiatrist warning him that this could affect his symptoms, the deputy said. Commissioner Dr Vanessa Caldwell.

The inadequate documentation has contributed to a distinct lack of clarity and action on changes in the man’s care, treatment plans and expectations, said Caldwell, who found that Te Whatu Ora and a psychiatrist violated the code in place to protect the patients.

There was a collective failure by several doctors at various crisis touchpoints and at the whnau meeting to offer adequate support to the man following his growing discomfort that was entirely to be expected, Caldwell said.

Te Whatu Now unreservedly accepts the findings and the violation, said Executive Clinical Director of Mental Health Services, Paul Oxnam.

We would like to take this opportunity to once again express our sincerest condolences to the people whnau on the loss of their loved one and to apologize for the shortcomings in the care we have provided.

She accepted the poor record keeping and communication with the man’s GP and the patient and his family should have been better supported after the whnau encounter which left the patient distressed.

The service has revised its audits to improve clinical processes and record keeping, Oxnam said.

An audit was developed to improve record keeping and ensure timely communication between MHAIDS [the mental health service] and other suppliers. We also intend to review systems within teams to ensure adequate support is provided to the person and whnau following whnau hui and other situations where discomfort may be experienced, Oxnam said.

Oxnam confirmed that the psychiatrist found in violation of the code is retired and no longer provides any psychiatric services, including locum or casual contracts at Te Whatu Ora. Caldwell withdrew his recommendations regarding his practice based on this.

The Deputy Commissioner also recommended that both Te Whatu Ora and the psychiatrist provide a written apology to the whnau man and that Te Whatu Ora provide a written reflection to the HDC on what he had learned from the tragedy within three months.