Internal communications at Tauranga Hospital's mental health unit are being slammed in a Health and Disability Commissioner's report on a patient's suicide.

In a report the commissioner criticises the performance of individual staff including a psychiatrist, Community Mental Health and Psychiatric Acute Community Team members in a four month period leading up to the man's death in 2010.

The Bay of Plenty District Health Board's Mental Health Unit is being slammed by the Health and Disability Commissioner.

The commissioner finds the DHB didn't comply with national mental health sector standards or the organisational standards of discharge planning.
It failed to take appropriate steps to discuss the man's discharge with his former partner, and failed to further assess the man when his increased risk factors for self-harm were known and identified.

The commissioner found the DHB failed to provide a continuity of care.

Of most concern was a failure of co-ordination between the psychiatrist, the PACT team and the failure to notify staff of the first point of contact.

The 45-year-old man was diagnosed with bipolar affective disorder, personality disorder with mixed features, and cyclothymic disorder in 2006.

He had been a community mental health patient from 2007 until 2009.

In 2010 his partner approached the psychiatric acute community team saying the man wasn't taking his medication, and his abusive behaviour had caused her to move out of her house.

PACT advised her to see his GP but did not inform the GP of the contact.

The man attempted suicide a month later.

When hospitalised he 'was reluctant to engage in an assessment by PACT”.

He was discharged from the Emergency Department and put into respite care because he had nowhere to go.

His former partner said her decision that she could not live with the man because he was not well or safe to be around.

She stated that from her perspective "there were no relationship issues as such -the issue was one of his illness, not the relationship”.

The next month he attempted suicide during an outpatient assessment by another psychiatrist, and was admitted to the intensive care unit.

He was discharged following an assessment by the consultation-liaison team psychologist, who found no acute mental illness and no acute risk, as relationship issues with his partner appeared to be resolved. The woman wasn't consulted.

Upon release he returned to the woman's home.

She agreed he could stay on condition he took his medication. She organised for his pills to be dispensed in blister packs in an attempt to keep track. Within weeks, he stopped taking them and became increasingly aggressive.

After two referrals from the GP the man underwent a psychiatric outpatient reassessment by the psychiatrist.

It was unable to be completed and another appointment was arranged a month later when the psychiatrist returned from leave.

The GP was astonished the man didn't fit any acceptance criteria for the community mental health service, and noted the man's steady declining mental state over five years.

The second referral was triaged as non-urgent and the GP was complained of by the intake co-ordinator saying his tone was "threatening and unhelpful".

The psychiatrist made an interim crisis plan where a psych nurse was to be the man's point of contact for any concerns or crises during working hours. Only those three; the psychiatrist, the nurse and the patient, were aware of the psych nurse's role.

The psychiatrist's handwritten notes were placed on the man's hard file but the notes didn't document the crisis plan or the role of the psych nurse, and neither the GP or his ex-partner were informed of the assessment outcome.

The former partner then approached PACT three times in three days in the second week of the fourth month with concerns about the man's behaviour and his threats of suicide.

Apart from advising her to take steps to remove the man from her home, the PACT did not respond.

The man's electronic record showed that he attended a psychiatric outpatient appointment two weeks earlier, but the PACT overlooked this and did not access his paper file.

The mental health services were aware that the relationship breakdown and his imminent eviction were significant risk factors for his self-harm, but no arrangement was made to review the man, who was found dead a few days later.

Communication issues noted by the commissioner include the fact the community mental health team considering the first GP referral was unaware of the man's prior mental health history.

Also the failure to inform the CMH intake co-ordinator of the man's acceptance for CMH assessment, and the confusion about whether the psych nurse was appointed case manager. The commissioner found the DHB also failed to communicate adequately with the GP after the ex-partner's visit to the PACT in month one, and when processing his two referrals to CMH in month three.

The failures in co-ordination between CMH, the PACT and the GP impaired the man's continuity of care.

In the report the commissioner says he's unable to comment on changes to the referral protocol and discharge review protocols because the DHB says they are on hold pending a review of the intake co-ordinator role.

The commissioner gave the DHB until October 31 to review its operating procedures and polices in light of the report and provide HDC with evidence of changes made, staff training, and planned follow-up/audits, in respect of:

The CMH referral handling process, specifically addressing direct communication with referrers, and internal communication of decision outcomes.

The triage/intake co-ordinator role, including the requirement to access prior records, and direct communication with referrers/GPs.

The training of mental health staff regarding discharge planning, and the involvement of whānau/family and other providers.

The case management allocation process, documentation and training to ensure clarity of team members' roles.

Clarification of the role and expectation of health professional/s taking part in assessments.

Ongoing education and staff support relating to the management of patients with severe personality disorders.

The DHB is ordered to provide a written apology to the dead man's former partner for its breaches of the Code. The apology was to be forwarded to HDC by 15 October 2012.

The dead man's former psychiatrist is also ordered to provide the woman with a written apology for his breaches of the code – and he is to undertake training on the DHB documentation standards protocol "Health Record - Content and Structure Policy 2.5.2, protocol 2" and provide HDC with evidence of training having been undertaken, and report to HDC any changes made to his practice.