Failures In Care Of Disabled Client Placed In A Forensic Psychiatric Unit 21HDC01302

In a report published today, Deputy Commissioner Dr Vanessa Caldwell has found Health New Zealand | Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights (the Code) for care provided to a client residing in a secure unit.

The client had been diagnosed with Fetal Alcohol Spectrum Disorder (FASD) and had a mild intellectual disability. Despite having no history with mental health services, the client resided in the clinic’s forensic psychiatry medium secure unit, as there were no suitable beds in Health NZ’s Forensic Intellectual Disability Secure Services (FIDSS).

Concerns were raised with HDC by a lawyer, following a restraint by clinical staff which resulted in the client sustaining an injury that caused pain and required surgery.

The incident occurred while the client was being accompanied to a high-care area, a decision taken because the client had become angry and verbally aggressive.

A struggle ensued between the healthcare assistant, registered nurse, and the client. The client was injured when all three fell to the ground.

Dr Caldwell found Health NZ breached the Code for failing to provide an appropriate standard of care | tautikanga.

"I am critical that systemic issues culminated in the client being seriously injured during a restraint," Dr Caldwell said. "Ultimately, Health NZ has an organisational responsibility to provide a reasonable standard of care to its residents. That did not occur in this case."

HDC found several failings in the care of the client, including a failure to employ de-escalation strategies and manage the client’s restraint adequately, seclusion being initiated by healthcare assistants without the leadership of a registered nurse, and in breach of the seclusion policy, and a lack of documentation surrounding the events.

Dr Caldwell said it is concerning that the client who had specific vulnerabilities was not cared for appropriately and that staff did not seem to be trained sufficiently to take these needs into account.

She said it highlighted a lack of suitable facilities for people with co-existing conditions and the appropriately trained staff to provide care for them.

"I have raised this matter previously with Health NZ, the Ministry of Health and Whaikaha and expect that as a system we can coordinate resources to better meet the needs of our most vulnerable."

Dr Caldwell commended Health NZ for undertaking an adverse event investigation in a comprehensive and patient-centred manner and was satisfied that they had appropriately identified six broad areas where things went wrong.

However, she was concerned that some of the key improvements were not implemented in a timely manner. Health NZ updated HDC on its progress towards implementing the recommendations a year after the recommendations were made, and two and a half years since the events.

© Scoop Media