Mental Health 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 care of a young man with mental
health issues, including suicidal ideation.
The Police found the young man in a situation where he appeared to be at risk of self-harming. They took him to a public
hospital, where he was admitted for assessment under the Mental Health (Compulsory Assessment and Treatment) Act 1992.
The following day, a child and adolescent psychiatrist assessed the man. The man told the psychiatrist that he was not
willing to take medication but was willing to receive other help from the DHB’s youth mental health service (the
Service) at the hospital.
The next day, the psychiatrist discharged the man from hospital without medication, and with the plan that he would have
a follow-up appointment with a Service nurse. The psychiatrist told HDC that she briefly discussed this discharge with
the man’s mother, but the man’s mother stated that the psychiatrist did not directly give her any information about the
discharge or follow-up care.
Over the next two months, the man met with a Service nurse several times to discuss his mental health. He then decided
that he no longer wanted support from the Service, so the meetings with the Service nurse were discontinued. At no point
was the man’s case discussed at a multidisciplinary team review.
Tragically, the man died the following year by suspected suicide.
Mental Health Commissioner Kevin Allan was critical that the man did not have a further psychiatric review after his
discharge from hospital, and that there was no multidisciplinary team involvement in his care. He was also critical of
the DHB for not involving the young man’s mother more closely in his care.
"There was a lack of comprehensive formulation of risk over a period of time, and a lack of guidelines for risk
management to be used once [the man] was discharged," said Mr Allan. "[The man’s] mother was not involved in his
psychiatric assessment while he was an inpatient, and so [the clinician] was unable to gather background information
about his circumstances in order to expand the risk assessment. The failings by the DHB clinicians resulted in [the
man’s] risk not being appreciated, and he and his family feeling unsupported."
Mr Allan recommended that the DHB arrange training for its Service staff on communication with patients and their
families, and on clinical assessment (particularly risk assessment); review all patients seen and discharged by the
Service during a one-month period to assess whether risk assessments have been assigned appropriately and
multidisciplinary meetings have been undertaken; and apologise to the man’s family.
The full report for case 18HDC00903 is available on the HDC website.