Deputy Health and Disability Commissioner Kevin Allan today released a report finding a district health board (DHB) in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the mental health care
of a woman with depression and suicidality.
The woman, aged in her thirties, had a history of depression, post-traumatic stress disorder, and significant mental
health issues. She had previously received compulsory treatment under the Mental Health (Compulsory Assessment and
Treatment) Act 1992 at the DHB.
The woman’s GP made an urgent referral to the DHB’s Mental Health Service for an assessment, owing to the woman’s
depression and suicidality. It was determined that she would be reviewed the following morning but, sadly, she died by
suicide before any assessment was carried out.
Mental Health Commissioner Kevin Allan was critical that the DHB had seriously inadequate systems and processes in place
at the time of the woman’s referral. In particular, there was no formal process for triaging referrals, and e-referrals
were managed by administrators without review by a clinician for up to 24 hours. Clinicians were also unable to access
patient medical records easily, and they had to manage crisis calls in addition to their usual caseload.
"The DHB is responsible for the services it provides, and must ensure that appropriate systems are in place to support
clinicians to carry out their roles," said Mr Allan. He considered that the inadequate systems and processes
"contributed to the poor standard of care provided in this case, with the result that opportunities to assess [the
woman] with the urgency required were missed."
Mr Allan noted that the DHB had "implemented a number of substantial changes since these events, which should improve
its service quality."
Mr Allan recommended that the DHB update HDC on its newly developed mental health crisis service manual, conduct an
audit of the current process for the management of incoming mental health referrals, and provide evidence of caseload
reviews carried out for Mental Health Service clinicians and report on the effectiveness of those reviews. He also
recommended that the DHB provide a written apology to the woman’s family, which has since been provided.
The full report for case 18HDC00078 is available on the HDC website.