Mental health care not cause of suicide
The suicide of Sam Fischer in Wellington Hospital’s secure mental health unit was not due to poor care, a coroner has found.
After five years of waiting, Fischer’s mother Lyn Copland said the findings were ‘‘a complete whitewash’’ and
‘‘a slap in the face’’.
Fischer, 34, died while under Capital & Coast District Health Board’s care in April, 2015. His death was only the second in the hospital’s secure mental health unit in 20 years.
Coroner Peter Ryan found that Fischer took his own life.
He said the care provided to Fischer was ‘‘reasonable’’ and ‘‘within accepted standards’’.
‘‘Mr Fischer’s death did not occur because of the quality of care and treatment provided to him. Rather, his death occurred in a background of an extremely complex mental illness of long-standing.’’
However, he said there were lessons to be learned and the health board had implemented changes that were likely to reduce the chances of further deaths in similar circumstances.
The findings did not specify what those lessons or changes were. It did refer to previous critical reports, which found a failure to consider Fischer’s long history of suicide attempts, problems with clinical records and concern there were too many cooks in Fischer’s care, with the input of his mother and advocate.
Ryan reiterated the critical importance of clear documentation, after the last nurse who cared for Fischer said had she known his suicide history she would probably have checked in on him more often.
In his expert evidence, psychiatrist David Chaplow expressed surprise that some staff did not know Fischer’s long history of self-harm.
Capital & Coast has since introduced an over-arching care and risk plan.
Copland said the coroner’s threeparagraph conclusion was a complete whitewash. The report would not achieve the improvement in mental health care she had hoped for.
‘‘It’s a complete nothing, it lets everybody completely off the hook ... I’m saddened that the things that did go wrong were not looked at more closely and recommendations made that would help other families or other potential victims. None of that is going to happen out of Sam’s death and the legacy he would have liked to have left.’’
The conclusions also appeared contradictory, as the coroner’s statement that changes would prevent further deaths seemed to acknowledge mistakes were made, Copland said.
Fischer had experienced mental health problems since the age of about 15, suffering drug and alcohol problems.
On the day of his suicide, he rang his mother, pleading ‘‘I need my antidote’’. He had been held in Wellington Hospital’s secure mental health unit for his own safety for 11 weeks.
Staff who treated Fischer said his progress was ‘‘a bit like two steps forward, two steps back’’ and it was difficult to balance containment and treatment.
During his stay at the unit, Fischer ran up a $20,000 debt, after managing to apply for a credit card from the ward. On the day of his suicide, a social worker took him to a budget adviser to discuss his debt. He returned ‘‘clearly distressed’’ and trashed the unit’s bathroom.
Coroner Ryan found the debt was a significant contributing factor to Fischer’s overall stress. While wellintentioned, Chaplow found the budget adviser’s visit ‘‘odd’’ and ‘‘another stressor’’. Ryan did not criticise the social worker.
Capital & Coast DHB declined to comment until the findings had been publicly released.