Mental Health Commissioner Kevin Allan today released a report finding a District Health Board in breach of the Code of
Health and Disability Services Consumers’ Rights for the care provided to a woman with mental health and addiction
issues.
The woman was admitted to hospital following an episode of self harm with a history of anxiety and depression and daily
alcohol use. She was reviewed by the Psychiatric Emergency Service (PES). The PES case manager verbally consulted with a
clinical nurse specialist at the Community Alcohol and Drug Service (CADS) and requested a referral to the service
regarding the woman’s alcohol use. CADS understood that PES would be continuing to work with the woman with regard to
her mental health issues. However, after PES was unable to make further contact with the woman she was discharged by
PES.
The woman later spoke with CADS by telephone and was referred to the Alcohol and Other Drug Coordination Service (AOD).
The PES referral to CADS was withdrawn. The plan was for the AOD service to organise an assessment for the woman in a
few weeks’ time. However, the woman had no further contact with DHB services before she was found to have passed away.
Mr Allan found that DHB staff separated the woman’s mental health and addiction issues from one another, and that the
referral of the woman to AOD and her discharge from PES resulted in no one retaining clinical responsibility for her
mental health issues, when either PES or CADS should have done so. Overall, there was a lack of critical thinking in
relation to the co-existing disorders, resulting in inadequate co-ordination of care by the DHB. Mr Allan stated that
this highlighted the importance of an integrated system of health care for consumers with co-existing mental health and
addiction disorders.
Mr Allan recommended that the DHB review and update its Service Provision Framework to ensure that it explicitly
clarifies and documents the transfer processes between services, the CADS criteria for acceptance, and the CADS
telephone screening process; and provide evidence of changes made as a result of the review, and details of any other
improvements to the interaction between PES, CADS, and AOD services. It was also recommended that the DHB provide an
apology to the woman’s family.
11 February 2019