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 man during an acute
admission to a mental health facility.
The man, aged in his thirties, had a history of severe depression, and was admitted to the DHB’s mental health facility
because of a significant deterioration in his mood and suicidal ideation. While at the hospital, the man jumped from the
roof of the High Care Area (HCA), sustaining fractures to both ankles.
There was a four-and-a-half hour delay in transferring the man to the emergency department at the public hospital to
have his injuries assessed. He was transferred to the emergency department in a taxi. The man subsequently underwent a
number of operations to repair his injuries.
Mental Health Commissioner Kevin Allan was critical of the inadequate level of observation assigned to the man before
the incident, and considered that the man should have been under closer supervision in the HCA courtyard. He also found
that the man’s transfer to the public hospital was not carried out in a safe or timely manner, and that a person with
possible fractures should be transported in an ambulance rather than a taxi.
"I consider that the overall picture of [the man’s] condition was not taken into account in the decision-making of staff
to ensure a safe physical environment and prompt action after the incident," said Mr Allan.
Mr Allan recommended that the DHB amend its observation policy to direct staff to maintain the assigned level of
observation whilst a consumer is smoking; review local clinical documentation on observations; and undertake an audit of
ten hospital transfers to ensure adherence to guidelines.
He also recommended that the DHB consider the recommendations of HDC’s expert advisor that a registered nurse remain in
the outdoor area of the HCA or maintain continuous line of sight whenever a consumer is in the outdoor area; review the
outdoor area for risk of absconding; remind staff that supervision of smoking is not the only factor determining the
need for observation; and review existing policy on transfer to acute medical care. Finally, Mr Allan recommended that
the DHB provide a written apology to the man.
The full report for case 18HDC02113 is available on the HDC website