External review of MDHB Mental Health Services makes 44 recommendations
An independent external review of MidCentral District Health Board’s mental health service following the apparent
self-inflicted deaths of two inpatients earlier this year, has made 44 recommendations for improvements to the service.
The review was carried out at the request of the MDHB board, in consultation with the Ministry of Health’s Director of
Mental Health, after two deaths in Ward 21 three weeks apart in April and May 2014.
The external review was commissioned to ensure that any underlying issues in relation to the structure, resourcing, or
culture of the service be identified and addressed.
The review team made 44 recommendations that have been accepted in full for implementation. Planned actions are due to
be endorsed by the Hospital Advisory Committee meeting on Tuesday. A work programme has been developed to address these.
A dedicated project leadership resource is being secured to support this programme of work, and to ensure that it is
robustly managed. Progress with the actions to address the recommendations will be reported six-weekly to the Board via
the Hospital Advisory Committee.
A root cause analysis review of each serious adverse event was also undertaken. These were carried out internally using
MDHB staff that are trained in the root cause analysis methodology. The implementation of the recommendations from these
reviews has been incorporated into the work programme.
An independent clinical review of both cases is planned. An approach is being made to a suitably qualified senior
clinician, and terms of reference drafted.
The service’s new Clinical Director Syed Ahmer, who took up this role on 4 August, in collaboration with the Director of
Nursing Michele Coghlan, and Director of Allied Health Kim Fry, will lead action in strengthening clinical governance
and clinical leadership.
The Operations Director Nicholas Glubb, and Dr Ahmer will, in consultation with the Directors of Nursing, and Allied
Health, review the service’s key leadership roles, reporting lines, accountability, good relationships, and key
partnerships at every level of the Mental Health Service.
For 2013/14 the budgeted staffing for medical staff for the mental health service was increased from 17.3 to 19 FTE. A
key impact is to enable a second full time psychiatrist to be appointed permanently to Ward 21. Both inpatient posts
have been filled with permanent full time psychiatrists since July 2014.
Mr Glubb said: “These two events were tragic outcomes for those patients and we express our deepest sympathy to the
families. We also acknowledge that the issues that have arisen regarding their family members care and the functioning
of the mental health service have had a profound and distressing impact on both families.
“This recognition is crucial motivation for all our staff to ensure that every opportunity is fully explored to learn
from these events and improve our services, particularly as a consequence of what has been recommended for action from
the reviews that have been undertaken.”
A copy of this report and the action plan will be made available to the two families for their feedback regarding our
response to the external review report recommendations.
Review and evaluation form a key component of all aspects of the work programme, and the review team has been asked to
revisit in 12 month’s time.