Review faults killer’s care

In March 2016 the woman, now 26, was found not guilty of the murder and assaults by reason of insanity. She was made a special patient at a secure forensic psychiatric ward where she remains.

The family of a mentally ill young woman who killed one person and stabbed four others after being sent home from Wellington Hospital continue to have concerns after a report scrutinising her care.

A recent review of the Wellington region’s mental health services found multiple failings in their care of the woman when it investigated her case, and those of four other patients involved in homicides within a 13-month period ending last March.

Notes from an unredacted version show the woman ran on to a road between cars, then had to be restrained at Wellington Hospital’s emergency department, and was observed by the Crisis Assessment Team (CAT) faking the taking of her anti-psychosis medication, quetiapine.

But the hospital sent her home after she appeared to calm down and take another pill. It also identified pressures on the availability of full acute mental health ward beds at the hospital.

The young woman’s family were dismayed to learn from the more detailed version of the review that the mental health carers seeing her that day had not had access to her full patient history, and that no other ways of administering anti-psychotic medication were considered.

It also showed none of her clinical notes had any entries about whether the medication she brought with her was quetiapine, or whether there was an observation period to ensure it had taken effect.

Blood tests following the stabbings on July 1, 2015, revealed there was no trace of the drug in her system.

‘‘In the end the facts cannot be ignored. A patient who had shown violent symptoms earlier in the day was allowed to go home unmedicated, and without having seen a psychiatric doctor,’’ her family said.

A court would later hear she had twice thrown her medication back at her GP and thrown punches at him earlier that day, and he had sent her to the hospital recommending she be committed to a ward under the Mental Health Act.

A judge found she was suffering from schizoaffective disorder when, instead of being committed, she was sent home.

The independent review found no one person or system to blame, but highlighted ‘‘multiple gaps’’ in her care.

The previously unpublished portion of the review also revealed a mental health worker was told of the woman’s ‘‘tragic incident’’ and, almost three hours after the stabbings, made multiple amendments to her electronic file over 20 minutes.

‘‘The review team was concerned at amendments to electronic documents being made after the incident,’’ the review says.

The amendments included details that she wanted to be with her family, had no violent history, and had accepted medication.

Capital & Coast said this week: ‘‘The file was accessed to add more detail – not to alter the existing information.

‘‘After learning of the homicide, staff members were asked to record any extra detail so the information was not forgotten,’’ mental health, addictions and intellectual disability services manager Nigel Fairley said.

‘‘We knew additions were being made, and that they would be recorded in the electronic health record after the homicide had occurred.

‘‘When incidents of this nature happen, there are coronial reviews and other investigations. It is important that the coroner and other reviewers have comprehensive and accurate information.’’

The woman’s family said of the notes: ‘‘It is not surprising that additional notes are sometimes added to complete the picture. However, it appears these particular comments were made fundamentally to justify their earlier activities, knowing what had happened, rather than dotting the i’s and crossing the t’s.’’

The DHB said work was under way on the eight recommendations in the review, in particular efforts to develop a single electronic health record. – Fairfax NZ