Deputy Health and Disability Commissioner Kevin Allan today released a report finding a Bay of Plenty District Health
Board (BOPDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failings in its
care of a young man requiring mental health services.
The man was admitted to the Mental Health Ward for two nights, with suicidal ideation. After he was discharged, he was
seen regularly by a psychologist from the DHB, and his care was discussed at multidisciplinary team meetings. However,
he was not seen in person by a DHB psychiatrist, either during his admission or after discharge. Tragically, he died the
"There was a striking lack of psychiatrist input into the man’s care, and the processes of discharging and transferring
the man from the various parts of BOPDHB’s Mental Health Service were extremely poor," Kevin Allan said.
Mr Allan was critical that the man was not seen by a consultant psychiatrist during his hospital admission, and not
given the opportunity to meet with a psychiatrist when he continued to be unwell. The multidisciplinary team did not
play an effective role in optimising the man’s care, and the man did not have a case manager separate from his BOPDHB
BOPDHB’s failure to formulate and communicate a written plan with the man for his discharge from the community mental
health service, and to communicate this to his family, GP and private psychologist, was also criticised.
Mr Allan recommended that BOPDHB provide feedback on the implementation of the recommendations made in its serious
incident review; and consider introducing a procedural requirement for community mental health service clients to be
seen by a psychiatrist every three months.
He also recommended that BOPDHB review its processes for discharging clients from the community mental health service to
ensure that a clear and comprehensive plan is established; and that BOPDHB and the consultant psychiatrist provide a
written apology to the man’s family.
Kevin Allan is the former Mental Health Commissioner. This role was transferred to the new Mental Health and Wellbeing
Commission in February 2021. However, HDC retains its complaints resolution role in relation to mental health and
The full report on case 18HDC00288 is available on the HDC website