DHB apologises after patient’s suicide

THE circumstances around the death of a mental health inpatient is to undergo further scrutiny.

Mental Health Commissioner Kevin Allan has found a district health board failed to care for the man who died four days after attempting suicide in his room.

Mr Allan found the DHB in breach of the Code of Health and Disability Services Consumers’ Rights for failures in the care of the man at a mental health inpatient unit, and has referred the DHB to the Director of Proceedings.

The man in his 60s had a complex clinical background including a history of mental illness.

After he was admitted for diagnosis, his condition deteriorated.

He was monitored over the weekend, but on the Monday morning — during three hours when he was not checked — he attempted to take his own life, and died four days later.

The commissioner found the DHB failed to transcribe possible diagnoses on to the man’s admission form accurately, to fully document a medical plan for care or to document a nursing plan.

The DHB also failed to ensure the man’s room was checked for risk points, to complete hourly observations after 6.30am, and to escalate the man’s care when his condition deteriorated.

The DHB did not have appropriate policies for observations and escalation of care.

Allan made recommendations that the DHB finalise an escalation policy and provide evidence of training on this, audit staff compliance with hourly observation plans, assess and provide training on communication and teamwork skills within the team, conduct a review of risk assessments, and check that new handover and admission forms captured relevant information.

He also recommended that the DHB apologise to the man’s family, which it subsequently did. — RNZ