Man‘s death deemed collective failure of system

The Human Rights Review Tribunal called the case a “collective failure of the system”. Photo: Jonathan Rados/ Unsplash.

The Bay of Plenty District Health Board breached the human rights of a man who took his own life when it failed to treat him with “reasonable care and skill” to maintain his mental wellbeing and prevent his death, a legal tribunal has ruled.

The Human Rights Review Tribunal says: “This was a collective failure of the system and the people operating in it, for which ultimately the Bay of Plenty DHB was responsible.”

The DHB also admitted that this was a “tragic case involving a number of failures in its care”.

Legal proceedings were filed against the DHB in the tribunal, which ruled they had breached two rights of the Code of Health and Disability Services Consumers’ Rights by failing to provide services to the young man with reasonable care and skill, and by failing to ensure there was effective collaboration to ensure quality and continuity of services.

The man first had contact with the DHB’s Mental Health and Addiction Services in July 2014 after his parents and his GP became concerned about his low mood and behaviour.

From that point, until March 2017, there was frequent contact with these services, and he had one voluntary admission to hospital after self harming.

Clinical notes over this time variously describe the man’s low mood, depression, social anxiety, insomnia, self-harm attempts and suicidal ideation.

On March 31, 2017 he was found dead near his home.

The Bay of Plenty DHB acknowledged that this was “a tragic case involving a number of failures in its care”.

In particular, when he was admitted to hospital as an inpatient in August 2016, he was not seen by a senior medical officer within 24 hours of admission or at all before being discharged from inpatient care, which was inconsistent with protocols.

There was no senior psychiatric input into the decision to discharge him, and his family was not told of his follow-up appointment with a consultant psychiatrist. When he failed to turn up to that appointment, he was discharged from the psychiatrist’s care, which reflected “poor clinical judgement”.

At this time, the mental health services team was aware that the man was particularly depressed, yet there was no psychiatry review between August 2016 and March 2017.

In February 2017 he began seeing a private psychologist and because of this, when his mother requested an urgent appointment on March 6, 2017 with the DHB’s Community Mental Health Services, he was denied the appointment as the DHB psychologist cited a perceived conflict of interest with his private practitioner.

This was despite the fact that his GP had referred him to the Community Mental Health Services crisis team in February 2017 after he expressed suicidal thoughts.

There was no discharge plan made or shared to the private psychologist, despite records showing that he had “a high level of risk,” and that his mother had expressed concern for his safety after she found that he was self harming and visiting suicide websites.

In the tribunal’s decision, it is noted that the Bay of Plenty DHB accepted that the care provided to the man fell below the standard expected of a healthcare provider in New Zealand.

There was a lack of attention to the basic aspects of assessment, monitoring, communication and clinical decision-making, and inadequate consideration of the level and type of care that he required, it said.

The Bay of Plenty DHB has apologised to the man’s family and expressed “deep regret” over its failings to ensure that he received the support and treatment necessary to maintain his mental wellbeing and prevent his death.

The case was reviewed by the mental health commissioner last year, who made a number of criticisms about the DHB before referring it to a lawyer appointed under the Health and Disability Commissioner Act to decide if legal proceedings should be taken.

Proceedings were then filed against the Bay of Plenty DHB in the Human Rights Review Tribunal, which declared that it had breached the code.

The DHB has introduced changes to its protocols, including the standard of record keeping and a requirement that a three-monthly review of client progress is documented.

Where to get help

Annemarie Quill/Stuff

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1 Comment


Posted on 24-05-2022 16:36 | By Centurion

Once again, no consequences for those who failed to provide adequate care and treatment. An apology to the family is the best they can do, and how often do we see that as a response to identified failings?

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