Deputy Commissioner Dr Vanessa Caldwell has found a District Health Board (DHB) in breach of Right 4(1) of the Code of
Health and Disability Services Consumers’ Rights (the Code) in relation to their care of a man in their forensic mental
health unit.
Dr Caldwell considered there was a lack of clear assessment and planning in relation to the management of the man, who
had been transferred to the forensic unit from prison where he was displaying agitated and aggressive behaviours. The
man self-harmed while in the forensic unit.
Dr Caldwell considered that it was unclear whether important information about the man’s level of risk was communicated
to nursing staff adequately.
She also noted that for people who experience acute episodes of distress, relative risk of self-harm changes rapidly and
frequently, as occurred in this case. The Deputy Commissioner acknowledged that the DHB had a range of tools to assess
and manage risk, but considered there was room for improvement in the way risk is communicated.
Dr Caldwell recommended, among other things, that the DHB provide an update on the changes it has made to risk
assessment and communication, and provide a written apology to the man and his family.
Dr Caldwell also wrote to the Ministry of Health to request support for the development of consistent risk management
and safety planning protocols to replace the practice of risk prediction.