MidCentral District Health Board and a mental health nurse have been found to have breached the code of health and disability services consumers’ rights.
A mental health nurse and a district health board have been found to have failed to properly treat a man with acute mental health needs who died by suicide.
The MidCentral District Health Board and a crisis assessment and treatment team mental health nurse were found, in a report released by the health and disability commissioner on Monday, to have breached the code of health and disability services consumers’ rights in 2018.
A man, who is not named in the report, became unwell while working in a remote location and was taken to be seen by the health board’s acute care team.
He was assessed by two mental health nurses, then returned home to his family in another district health board region.
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The man’s mother was concerned about his wellbeing and took him to the closest emergency department that evening, and clinicians referred him to the crisis assessment and treatment team.
This team was based in another town, and the mental health nurse spoke with the man’s mother on the phone, but did not speak with the man directly.
The man was advised to return home with a sleeping tablet and be seen by the crisis assessment and treatment team in the morning.
He died of suspected suicide the next morning.
Mental health commissioner Kevin Allan considered clinicians did not ensure the man received an adequate mental health assessment and the management plan was inadequate.
Allan believed the district health board didn’t care for the man well enough.
“As a result of these failures, an opportunity was lost to identify the extent of [the man’s] illness and access appropriate treatment, and [the man] did not receive continuity of services.”
Allan was also critical the crisis assessment and treatment team mental health nurse did not seek to assess the man’s mental health status when she first spoke to his mother; did not assess or speak with the man at any stage; and developed her safety plan in the absence of an adequate assessment of the man’s mental health.
The nurse also did not consider herself responsible for the safety plan she developed and she dismissed concerns raised by a colleague.
Allan recommended the district health board update the health and disability commissioner on its review of documentation and training for clinicians who work with the acute care team; provide training for acute care team staff about mental health assessments for people from outside the area unknown to the service; and apologise to the family with input from the nurses involved.
He also recommended the other district health board involved, which was not named, review its operations and apologise to the man’s family.
Allan recommended the crisis assessment and treatment team mental health nurse provide a statement on the changes to her practice as a result of this incident; provide evidence of her training on the assessment, management and care of patients who seek help while having suicidal thoughts; and apologise to the family.
He also recommended the Nursing Council of New Zealand consider whether a review of the registered nurse’s competency or conduct is warranted.
MidCentral District Health Board acting chief executive Tracee Te Huia said: “We accept the Health and Disability Commission’s findings and can advise that the recommendations contained within are well progressed.
“A number of these relate to guidelines that are in place as well as ongoing education and training for staff. We are assessing our documentation, training and development needs within the acute care team.”
A letter of apology to the man’s family had been sent.