‘Three years and this is what they came up with’
Grieving parents of Cassandra Fausett upset after several issues identified with mental health service, writes Alex Spence
A confidential review by Counties Manukau’s mental health service of the care it provided to a teenager who died by suspected suicide found several weaknesses in its operations, including “substantial and longstanding” workforce pressures, the Weekend Herald has learned.
Cassandra Fausett, 17, died in September 2019 after more than two years under the former district health board’s specialist child and adolescent (Camhs) mental health division. A review of Fausett’s care was started soon after her death but has not been made public until now.
The reviewers’ 11-page report identified six “areas of unsafe system operation”, including a lack of continuous oversight by a senior clinician, inadequate communication with Fausett and her parents, limited respite facilities for young people at times of crisis, and chronic staffing issues.
The document is dated January 2021 but was only provided to her parents, Caroline and Steve, last week. Caroline Fausett said she was disappointed with the report despite the critical findings and baffled that the health authority took so long to share it with them.
“This is nothing,” Caroline said. “You can’t tell me three years and this is what they came up with.”
The parents shared the report with the Weekend Herald because they want to highlight problems in the system. “I’m trying to get things to change so that other people don’t go through this,” Caroline said.
The review was limited in scope but highlights serious issues affecting children’s mental health services nationally.
Last year, a Herald investigation revealed children’s services across the country were underfunded, overstretched, and struggling to recruit and retain experienced staff — resulting in unsafe caseloads, compromised treatment, and patients turned away.
Health Minister Ayesha Verrall said the government is investing in early intervention services in primary care and schools that it hopes will eventually reduce demand on specialist providers. She said last year’s Budget allocated additional funding to support people with acute needs, which included $18.7 million over four years for Camhs. But there was still more to do, she said. Fausett had complicated mental health problems, including obsessivecompulsive disorder, anorexia, and possible autism spectrum disorder. She endured numerous hospital admissions and suicide attempts in the two years before her death.
She needed a “bespoke care pathway” overseen continuously by a senior professional, according to the four-person panel that reviewed her treatment.
Instead, the reviewers said: “different professionals came and went”.
“The quality of connection that CF experienced with different clinicians providing her care varied significantly. All significant clinical interventions and therapies were tried, but the lack of continuity of staff compounded the challenges that CF, her parents and her treating team faced.”
The report acknowledged Fausett’s parents experienced “significant and at times overwhelming stress” when their daughter was in crisis and Camhs provided limited options for family respite.
Across Counties Camhs, the reviewers said, a major restructuring and chronic workforce shortages limited the ability of staff to do much more than react to crises.
“The review team recognise that this was a workforce under stress, with a relatively junior workforce and with high demand. This combination is unfortunately evident in many Camhs throughout the country.”
On October 1, the Herald published an extensive report on Fausett’s experience with serious mental illness. In that article, her parents raised numerous criticisms of the mental health system — disconnected services that are confusing to navigate, constant turnover of professionals, poor communication, lack of safe alternatives for people at risk of suicide — that echoed those of dozens of other families and service users in our year-long investigation.
At the time, Counties (now part of Te Whatu Ora/Health NZ) declined to comment on Fausett’s care due to privacy considerations but said it was ready to share the findings with her parents.
The former DHB said it had “dropped the ball” in not discussing the findings of the review with Fausett’s parents sooner, partly because its processes had been disrupted by Covid-19.
On October 13, Counties’ clinical leadership met Caroline Fausett and briefed her on the review’s findings. Caroline said after that conversation she felt encouraged by the executives’ comments, but wanted to read the report herself, which she was not given at the meeting.
On October 25, she emailed one of the managers requesting a copy of the report and their notes from the meeting and was told they would be sent “in a few days”.
However, Caroline said she did not hear from Counties until this month after the Herald contacted it for an update.
Last week, Caroline was asked back for another meeting with senior management, where she was given a copy of the report for the first time. She shared it with Steve, who said he had not had any discussions about the review’s findings.
“Te Whatu Ora Counties Manukau apologises unreservedly for the delay in providing a copy of the report to Cassandra’s parents,” Charles Tutagalevao, general manager of mental health, said in a statement.
Changes have been made to ensure families are kept in the loop after serious incidents, he added.
In the report, the reviewers made five recommendations for improving Counties’ Camhs, including developing a
formal process to identify patients with “enduring elevated risk” and allocating a senior clinician to oversee their care; improving case review procedures; and ensuring families are involved in developing care plans.
Tutagalevao said all five recommendations had been implemented.
He said the staff vacancy rate in Counties’ Camhs has improved since
2019 and currently stands at 25.7 per cent. “We have seen a positive start to
2023 with the recruitment of newly qualified nurses.”
Fausett’s parents were surprised at the report’s brevity. They were disappointed it did not include several specific issues they believe were crucial to Cassandra’s experience in the service — including the management of her medications and their interactions with the service’s crisisresponse team — and it seemed to rely on clinicians’ notes they believe were not always complete or accurate.
“I don’t think they’ve taken on board what we were trying to say,” Caroline said.
She had high expectations the review would bring meaningful changes but now considers the process was a “complete and utter waste of time”.
“I have no confidence that change is going to be made,” Steve said.
Tutagalevao said Counties was trying to arrange another meeting, with both parents, early next month. “We will be open to discuss any specific concerns Steve and Caroline have about the report at this time,” he said.
The parents were also concerned a separate investigation into Fausett’s death by the Coroner’s office appears to be no closer to completion.
Caroline said they had not heard from the Coroner’s office for more than two years and had no idea whether its inquiry was progressing.
Coroners are required to investigate every suspected suicide but families often wait years for inquests to be completed, which can be stressful and traumatising for people already struggling to come to terms with tragedy.
“It’s a complete box-ticking exercise,” Steve said. “If they can’t bother doing it in a timely fashion, don’t bother doing it. The longer it goes on, the less relevance it has to anything.”
“It won’t effect change, it takes too long. So what’s the point?”
The Coroner’s office did not comment. But after an enquiry by the Herald this week, Caroline Fausett said she was contacted by the office and informed that the coroner investigating Cassandra’s death had left to become a District Court judge.
A new coroner will be assigned to the case, which will be the third change in three-and-a-half years. There was no update on when the inquiry was likely to be completed, Caroline said.
“Work is underway to review the processes for investigating deaths by suicide,” Verrall said.
Children’s services in crisis
Child and adolescent mental health services, known as Camhs or Cafs depending on the region, are the specialist services operated by Te Whatu Ora/Health New Zealand.
They treat about 50,000 Kiwis under 20 every year who are deemed to have a severe mental illness.
Last year, an investigation by the Herald revealed they were struggling to cope with a rising tide of distress after years of underinvestment and poor planning by successive governments. Among the findings of our investigation:
• The number of young people seen by Camhs rose by 35 per cent in a decade but funding increased by only
25 per cent, according to Ministry of Health documents. Children’s services received about $3600 a patient, compared to $5800 a head spent on adult services, even though their work can be more intensive and complicated.
• Vastly more children and teenagers are experiencing a mental health crisis, but parents said there is a stark lack of support for people who are so acutely distressed that they are a danger to themselves. Hospital emergency departments and police have effectively become the first responders for many people in crisis.
• Shortages of psychiatrists, psychologists, nurses and other skilled staff had reached breaking point in some places, forcing services to raise thresholds for admission and restrict the care they provided. Inexperienced staff were being thrust into difficult roles with inadequate support and some complained of burnout.
• Only 39 per cent of Camhs patients were seen within 48 hours, compared to 63 per cent of patients in adult services, and nearly a third of younger patients waited more than three weeks for an initial appointment.
• Antidepressant prescriptions for children and adolescents had more than doubled in the past decade, while the evidence-based talk therapy that is considered the gold standard treatment for patients of that age was hard to access or unavailable in many places.
After one of the stories in our series, Andrew Little — the health minister at the time — acknowledged: “It’s under huge pressure”.
“There are areas where I know young people in particular are struggling to get the specialist attention that they need, waiting a long time to get it. That is in crisis.
“Child and adolescent mental health services are in crisis.”
Jo Chiplin, interim director of mental health commissioning at Te Whatu Ora, said there were “significant pressures on many mental health and addiction providers”, including children’s services, and the health body is “working hard on a number of initiatives to train, retain and grow the overall specialist mental health and addiction workforce”.
In the past three years, $87 million has been committed to workforce development.
In last year’s Budget, the government committed $18.7 million to expanding Camhs to support about 1300 more young people annually. Chiplin said: “Considerable work has gone into identifying priority areas for funding in the first two years, and this work is now completed”.
“The funding available will be used to expand Camhs services in four priority districts and to provide enhanced support for young people with mental health concerns who are under the care of Oranga Tamariki. Announcements will be made in due course.”