DHB faults in possible suicides

At least 208 suspected suicides reported by DHBs in the last year occurred while or soon after the person was under public health care.

The latest Health Quality and Safety Commission adverse events annual report showed 208 of the deaths mentioned were suspected suicides — 12 of which occurred in inpatient units.

The remaining 104 deaths were from other parts of the health sector.

The findings came a day after it was revealed 21-year-old Nicky Stevens’ death could have been avoided had his parents’ advice not to allow him unescorted leave been adhered to.

Stevens took his own life on March 9, 2015, after he was let out of the Henry Rongomau Bennett Centre at Waikato Hospital unescorted.

Commission chairman Professor Alan Merry said it was “incredibly concerning” when people in the system were failed and they committed suicide.

“That’s not to say its not complex . . . people can commit suicide no matter what. But there was a lot to learn from this,” Merry said.

For the first time since 2013, the mental health and addictions (MHA) sector of the DHB was included in the report.

In total, 982 adverse events — unexpected or unplanned events that resulted in harm or death — were reported in the last year by private and public health services.

Of the 631 events that were reported by health boards, 317 of them were due to clinical management and 255 were falls that resulted in serious harm. Other highlighted reporting categories included healthcareassociated infections and medication.

The year before, there were 542 adverse events reported by DHBs.

Merry said adverse events could have a devastating effect on the person involved and their wha¯nau and friends.

He said the commission would use the information in its MHA quality improvement programme.