S95 Inquiry into Hutt Valley DHB Mental Health Service Released 28 June 2012
The Director of Mental Health Dr John Crawshaw has today released the findings of an inquiry under Section 95 of the
Mental Health (Compulsory Assessment and Treatment) Act 1992, into Hutt Valley District Health Board’s Mental Health
Service.
The former Director of Mental Health commissioned the inquiry in June 2010 following serious allegations being raised
about the service.
The findings of the inquiry include management of the service, the role of the Office of the Director of Area Mental
Health Services, the monitoring and reporting of serious incidents and the Mental Health Service’s management and
clinical governance at the time.
The current Director of Mental Health, Dr Crawshaw, has accepted the inquiry’s recommendations.
Dr Crawshaw says the inquiry describes an unhappy chapter in mental health services in the Hutt Valley. ‘I extend my
sympathy to those individuals and their families involved in the inquiry and the two years it covers.
‘This thorough investigation has led to important changes in services which I judge to be entirely appropriate in light
of the issues covered by the inquiry.
‘I look forward to further strengthening of the mental health unit as planned changes are fully implemented.’
The Ministry of Health will monitor the DHB’s implementation of the recommendations.
Please see the attached report and background information.
Background information
Concerns were raised with the Director of Mental Health about various matters relating to the Mental Health Service at
Hutt Valley District Health Board. This included a number of serious allegations regarding services and clinical issues
pertaining to individual patients in addition to leadership and systemic issues.
Inquiry timeframe
The former Director of Mental Health commissioned the inquiry in June 2010. This report is being released following the
Director of Mental Health’s consideration of the findings. The Director’s considerations are also being released with
the report.
Major findings
1. Changes were needed in the management, including clinical management, of the Mental Health Service to ensure delivery
of appropriate services for patients.
2. There were failings by the service in meeting its statutory duties, including around the management, monitoring and
reporting of serious incidents.
3. DHB management and clinical governance functioning was not operating effectively.
Major recommendations
The Director of Mental Health has made a number of recommendations. This includes ensuring:
1. adequate staffing and nursing structure within the inpatient unit
2. stronger relationships between Intellectual Disability and Mental Health Services and between Wairarapa District
Health Board Community Mental Health Service and Te
Whare Ahuru acute inpatient unit
3. adherence with the requirements of statutory roles and clearer guidance around the
roles and their responsibilities
4. a review of the clinical governance structure.
Actions taken
Hutt Valley DHB
1. Positive changes to staffing. At the conclusion of the investigation, the DHB reported that the inpatient unit was
fully staffed.
2. Steps have been taken to strengthen ties with Wairarapa DHB including regular multidisciplinary and regional meetings
and assistance with staff covers.
3. The Hutt Valley DHB has improved relationships with District Inspectors with the aim of ensuring the Mental Health
Service meets statutory requirements.
4. Service and management structures have changed to strengthen clinical leadership across hospital services.
Ministry of Health
1. The Ministry will be working closely with the DHB to ensure the recommended changes are implemented.
2. The Director of Mental Health is liaising with the DHB to ensure that the required changes, prompted by the inquiry
recommendations, are taking place and will continue to monitor this progress.
Background to the Director of Mental Health issuing his own report
Because of the seriousness of the issues raised in the inquiry, it was important that the report was properly considered
by the Ministry of Health. The Director of Mental Health accepted the findings of the inquiry and recommendations. The
Director’s considerations and conclusions are set out in his report, which has been released along with the inquiry
report.