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Ellis inquiry findings released

22 October 2003

Media Release

Ellis inquiry findings released

The Ministry of Health and Counties Manukau DHB will continue to work together to ensure recommendations for improving its mental health services are put in place following the release of an inquiry's findings today.

Director of Mental Health Dr David Chaplow says since the incident which sparked the inquiry, the DHB has already implemented many of the recommendations made in the inquiry report. These include aligning inpatient and community services, and improving processes for involving family.

Other changes since the incident occurred in late 2001 include significant increases in funding for mental health services in the Northern Region and specifically in Counties Manukau, enabling growth and improving practice, and the appointment of an Auckland Regional Director Mental Health Services, says Dr Chaplow.

The inquiry report summaries released today found a number of inadequacies in the mental health services provided to Auckland man Paul Ellis, who fatally assaulted his father two years ago.

"The inquiry revealed overall failings in the system of mental health provision, such as poor communication, misunderstandings, and workforce inadequacies. However, improvements have already been made and will continue. I recognise nothing will reverse the tragic loss experienced by the Ellis family to whom, again, we extend our condolences," says Dr Chaplow.

The inquiry, conducted by Helen Cull QC, under provisions of the Mental Health (Compulsory Assessment and Treatment) Act, investigated the adequacy and timeliness of South Auckland Mental Health Services (now Counties Manukau District Health Board's services) provided to Paul Ellis and his family. It found there was no one factor that led to the fatal event.

"There were numerous deficiencies in the service, and the impact of resource constraints on South Auckland Health was a contributing factor to the delivery of services to Paul Ellis. The demands on the services, excess client numbers, large caseloads, the level of deprivation within the community, and severity of patient illness, reduced its capacity to provide him with adequate care."

The inquiry report has many recommendations on how Counties Manukau DHB's services can improve its systems. "This report contains lessons that all mental health services can learn from, and the Ministry will make the findings of the report available to all mental health services."

The report also makes one recommendation for legislative amendment. The Ministry will be discussing this further with key agencies and leaders.

The Government continues to place major emphasis on improving mental health services nationwide, says Dr Chaplow. Funding is available to promote workforce and infrastructure development. These needs are being addressed nationally, regionally and locally.

In the Auckland region, issues of service provision and demand are being addressed on a regional basis. Derek Wright is now the Auckland Regional Director Mental Health Services. He leads the group that is co-ordinating and planning care for people moving through the recovery process. He is also leading the process for establishing an Auckland Mental Health Coalition.

A copy of the Inquiry's summary of conclusions and recommendations is attached below the "Questions and Answers" section.

MEDIA NOTE: Dr David Chaplow will be available for media interviews between 1pm and 3pm this afternoon.

ENDS

http://www.moh.govt.nz

Questions and Answers

What was the inquiry?

On 26 October, 2001, Paul Ellis fatally assaulted his father. Paul Ellis was under the care of South Auckland Health's (now Counties Manukau DHB's) mental health services at the time, and 14 days previously had been compulsorily admitted to hospital, but discharged himself after a review conducted by a Family Court Judge found he could not be detained compulsorily under the Mental Health (Compulsory Assessment and treatment) Act 1992. After leaving hospital he received follow-up including visits from community mental health workers. Paul Ellis has since been found not guilty of murder on the grounds of insanity.

The Director of Mental Health Dr David Chaplow asked Helen Cull QC, Senior Advisory District Inspector, to inquire into the adequacy and timeliness of services provided to Paul Ellis and his family by South Auckland Mental Health Services in October 2001. Ms Cull was assisted in the inquiry by Dr Gail Robinson, a consultant psychiatrist, based in West Auckland. Dr Robinson was also appointed by the Director of Mental Health. The terms of reference were framed to provide for a wide-ranging inquiry as provided under section 95 of the Act. Mental health service provision, the functioning of relevant sections of the Act and any other recommendations that might affect the provision of services to a patient such as Paul Ellis and his family, were considered relevant subjects of inquiry.

What did the inquiry find?

Overall, the inquiry found that the services provided to Paul Ellis by the South Auckland mental health services were inadequate but there was no one factor, incident or person within the service responsible for the tragedy that occurred.

The inquiry report noted that it was a combination of errors, omissions, timing and circumstances that led to the overall inadequacy. The report also noted that the impact of resource constraints on South Auckland Health contributed to the inadequacy of services delivered to Paul Ellis. Excess client numbers, large caseloads, the level of deprivation within the community and the severity of patient illness reduced the capacity of South Auckland Health to provide adequate care.

The inquiry report recommendations include:

1. How South Auckland mental health services should improve the timeliness and adequacy of services provided to patients and families.

2. Whether there ought to be changes in service provision, or in policy or legal frameworks that would impact on the functioning/operation of section 16 of the Act.

What changes has Counties-Manukau DHB implemented?

Counties Manukau DHB has made extensive structural changes, implemented service development initiatives, and made quality process/documentation changes. It has also signalled further service developments. Also, since the time of providing care to Paul Ellis in late 2001, significant increases in funding for mental health services have been applied in the Northern Region and specifically in Counties Manukau, enabling growth and improving practice.

What will happen to ensure the recommendations made in the Inquiry report are implemented?

The Ministry intends to monitor Counties Manukau DHB and the Auckland regional DHBs to ensure that the report recommendations continue to be implemented. The Ministry will also consult further with a view to conducting a symposium that considers the policy and practice implications arising from the section 16 recommendations made in the report.

Will the recommendations affect mental health services in other areas?

The Ministry considers that all mental health services would benefit from application of relevant report recommendations. It intends to table the conclusions and recommendations for discussion with national Directors of Area Mental Health Services. It also plans to write to the CEOs of District Health Boards so that lessons learned from this inquiry can be utilised by all mental health services as a learning opportunity.

Could a similar incident occur?

The recent homicide study findings indicate that rare and tragic events do occur. However, such incidents are minimised when mental health services function optimally. "What's important is that we learn from tragedies like these, and commit to making the appropriate changes," says Dr Chaplow.

What has the Government done over the last two years to help improve mental health services in Auckland?

In April 2002, following publicly expressed concerns about the state of acute mental health services available in Auckland, the Minister of Health asked the Mental Health Commission (MHC) to undertake a review of the care provided by DHBs in the Auckland area to people with mental illness. The Commission's report, Review of the Continuum of Care of Mental Health Services Funded by the District Health Boards in the Auckland Region, was received in December 2002.

The MHC's Review recommended that steps be taken to improve the following aspects of mental health service planning, provision, and monitoring:

· co-ordination of services across the Auckland region

· service model development

· contract management

· contract monitoring

· system development

· primary care enhancements for mental health.

As a result of that review, the Minister of Health recommended, and Cabinet agreed, to bring forward $2.8 million (GST inclusive) from 2003/04 to 2002/03 to meet the costs of implementing the recommendations of the MHC's review, with no impact on the Government's fiscal provisions. This funding was paid to the Auckland DHBs on 4 April 2003.

On 1 April 2003, the Auckland DHBs announced that Derek Wright would be appointed as the Regional Director of Mental Health Services (an implementation of one of the recommendations of the review). The Regional Director would be responsible for creating a region-wide coalition that would bring leadership, cohesion and collaboration to the delivery of mental health services across the Auckland metropolitan region.

Since April, developments include:

· more ICU beds have opened

· the nursing bureau is prioritising nursing staff to be going into psychiatric services

· 20 planned packages of care in the Auckland region have been filled.

ENDS

The Inquiry's Overall Summary of Conclusions

The services provided to Paul Ellis by the South Auckland Mental Health Services were inadequate. There was no one factor, incident or person within the Service responsible for the tragedy that occurred.

However, it is a combination of errors, omissions, timing and circumstances which led to the overall inadequacy. It is one of the classical systemic failures, which failed Paul Ellis.

Reference is often made to the 'swiss cheese model of system accidents? in which successive holes in the layers of defences, barriers and safeguards line up. Refer Reason, J: ?Human Error Models in Management?, BMJ 2000, 320, 768 In our view, there were ?numerous holes? in this service which ultimately failed Paul Ellis and his family.

The impact of resource constraints on South Auckland Health was a contributing factor to the delivery of services to Paul Ellis. The demands on the services by excess client numbers, large caseloads, the level of deprivation within the community and the severity of patient illness reduced its capacity to provide adequate care to Paul Ellis.

Summary of Conclusions

to Terms of Reference

Term of Reference 1

Adequacy and Timeliness of Mental Health Services

Conclusion to Term of Reference 1.1

Were the Community Assessment Processes prior to hospital admission adequate?

The Community Assessment processes prior to hospital admission of Paul Ellis were adequate and timely. The communication and liaison from the Mental Health workers to the Police were also appropriate, adequate and timely.

Conclusion to Term of Reference 1.2

Assessment on admission, including any factors which may have compromised this

1. Initial Assessment

· The initial assessment of Paul Ellis on his admission to the Intensive Care Unit at Tiaho Mai was timely, having been conducted in the early hours of the morning between 1 a.m. and 3 a.m. on Friday 12 October. · The clinical examination and initial management plan that were documented in the inpatient file were adequate.

· The clinical report form, being a summary of the section 10 assessment, which was referred to the Judge for the section 16 Review, did not have an adequate space to give reasons on, and therefore did not address adequately, the second limb of the definition of ?mental disorder?, namely why Paul Ellis posed a serious danger to the health and safety of himself or others.

2. Ongoing Assessment

· The ICU (Kuaka) was four patients over numbers and the severity of illness in the ward was unusually high with staff having to intervene in altercations between patients. Nursing staff were unable to dedicate specific time to those patients who were presenting less of an imminent risk to themselves or others.

· The opportunity to assess Paul Ellis in an ongoing manner did not occur on the dayshift changeover from 7.30 to 11 a.m., which was the critical period before the section 16 Review, because of overcrowding on the ward and associated pressures on staff. This was both inappropriate and inadequate. · The reduced number of psychiatric consultants available and the severity of illness on the ward meant that the necessary ward-round took an extended period of time to complete. This significantly compromised the time available for Paul Ellis to be assessed by the appropriate mental health staff, following the abridgment of time, from 12 pm to 11 am, for the section 16 Review hearing.

Conclusion to Term of Reference 1.3

Communication about the scheduling of, involvement of family members in and information required for the section 16 Review hearing and presentation of opinion and evidence at that hearing

1. There was no involvement of Paul Ellis's family in his section 16 Review. His father, who was the section 8A applicant responsible for initiating the Mental Health Act procedures, was advised of the hearing by the [word deleted] nurse just prior to the Review, but [his/her] views were not available to the Judge.

2. The lack of contact details on the section 8A application form meant that the [staff member] could not contact Mr Ellis directly about the time of the section 16 review.

3. The decision to reschedule the section 16 Review from 12 p.m. to 11 a.m. resulted in the responsible clinician having insufficient time to undertake an assessment of Paul Ellis at the end of his ward round. The abridgement of time also compromised adequate communication by the service with Mr Ellis Senior about the review hearing and his ability to be present.

4. The Judge received copies of the Mental Health Act documents including the Clinical Report form, which was a summary of the section 10 psychiatric assessment. The Clinical Report form however, did not elaborate on the second limb of the definition of ?mental disorder? namely, why Paul Ellis was a serious danger to himself or others.

5. The communication among ward staff, the Court and Paul Ellis's lawyer about the scheduling of the section 16 review application by Paul Ellis was timely and efficient.

6.

(a) The scheduling of the section 16 Review, whilst prompt and efficient, was

adequate, until the time of the hearing was changed from 12 noon to 11 a.m.

(b) The abridgement of time on that morning at Tiaho Mai was inappropriate, in that it compromised the ability of the consultant psychiatrist to assess Paul Ellis as his responsible clinician, who must be consulted by the Judge as to the patient's condition for a section 16 Review.

7. The presentation of opinion and evidence at the section 16 Review hearing was neither appropriate nor adequate in the following ways:

(a) The psychiatrist could not provide a professional assessment or opinion as to Paul Ellis's condition.

(b) The second health professional could not proffer any informed opinion or assistance to the Judge.

(c) The psychiatrist, despite telling the Judge he had not seen the patient, proffered an opinion when asked by the Judge.

(d) The health professionals did not have sufficient time to assess the patient;

(e) The responsible clinician and the second health professional did not have adequate input.

(f) There was no consultation with persons other than the responsible clinician and the second health professional as to the patient's condition.

(g) The clinical assessments from the inpatient file were not reviewed or given any weight.

Conclusion to Term of Reference 1.4

After the section 16 Review Hearing

Assessment and advice immediately after section 16 Review hearing

1. The Inpatient psychiatrist was adequately informed of the process of re-assessment for Paul Ellis under the Mental Health Act.

2. The assessment by the psychiatrist was timely, occurring immediately after the section 16 Review, and was adequate and thorough, but was influenced by the outcome of the section 16 Review.

3. The decision to treat Paul Ellis in the Community and the medication prescribed was influenced by the psychiatrist's belief that: · he did not have the grounds to re-initiate the Mental Health compulsory processes and · Paul Ellis appeared more settled and was willing to accept treatment in the community.

Recommendations made for treatment and re-assessment in the community

4. The recommendations for treatment and reassessment in the community were inadequately documented and were not communicated to the community team. The responsibility for the various aspects of communication to the Community Service was unclear.

5. The discharge plans were inadequate and the recommendations for monitoring of medication dosage were absent.

6. Although the discharge plan written in the inpatient file stipulated the medication dosage, there were no further recommendations for treatment or for reassessment in the community. This was both inadequate and inappropriate in the circumstances.

Conclusion to Term of Reference 1.5

Communication and coordination between the In-patient and community services

The communication between the inpatient and outpatient services was poor and inadequate in the following ways:

· There was no clear coordination in the discharge of Paul Ellis from the Inpatient Service to the Community Service.

· The discharge referral form lacked critical information regarding Paul Ellis's diagnosis, medication and priority for follow-up.

· The Inpatient file remained in the Inpatient Service and pertinent clinical information, including the two Inpatient Psychiatric Assessments, was never sent to the Community Service.

· There was no discharge summary completed and communicated to the community team, which contributed to the Team's lack of relevant clinical information about Paul Ellis.

· No pre-discharge planning meeting was convened, due to the abrupt discharge from the Inpatient Service of Paul Ellis.

Conclusion to Term of Reference 1.6

Community treatment, re-assessment and follow-up, including whether this was sufficiently assertive

· The community team took appropriate steps to follow up Paul Ellis on the limited information that it had. However, the absence of a management plan which should have prompted the community team to obtain information from the Inpatient Service, compromised the Team's ability to treat and reassess Paul Ellis.

· The community team was insufficiently assertive in its follow-up of Paul Ellis, as it lacked relevant documentation and information from the Inpatient Service, was influenced by the outcome of the section 16 review hearing and was mistaken in its views on the risks of legal action.

· The lack of available clinical leadership and the paucity of resources had a negative impact on the community team's ability to be more assertive in the circumstances.

Conclusion to Term of Reference 1.7 Responsiveness to the concerns of the family and liaison with other emergency service agencies such as Police

1.7.1 Responsiveness to the concerns of the family

1. The Inpatient Service

The Inpatient Service contact with the family following Paul Ellis's discharge from Tiaho Mai was lacking in that:

· Mr Ellis senior never received a response from the consultant psychiatrist to his letter dated 14 October 2001. If the Consultant was concerned about ?confidentiality?, this issue should have been addressed with the family. This omission was an inadequate response to the family's concerns.

· The [words deleted] nurse failed to tell the family that Paul Ellis was prescribed medication or that he was to be seen as soon as possible. [He/She] also failed to advise the family that the Mental Health Act processes could be restarted. This was an inadequate communication with the family, as the information given to them was incomplete. · The [staff member] informed the family of the outcome of the Review, but it was inappropriate that this task fell to [him/her], as [he/she] was unable to advise them about the ongoing clinical needs for Paul Ellis.

· No-one from the Inpatient Service, in their contact with Mr Ellis senior, advised him that the Mental Health Act processes could be restarted or re-initiated.

2. Outpatient Service - Community team

· Both the [DAO] and the key worker responded appropriately to the family and took the family's concerns seriously.

· The key worker made several attempts to contact Paul Ellis to arrange visits and attend on him at an agreed time and place. [His/Her] attempts to respond to the family were influenced by the advice [he/she] had received from the DAO [words deleted], who advised [the keyworker] not to attend on Paul Ellis alone, or go to his home, because of the potential claims for harassment and trespass.

· In the absence of any relevant information from the Inpatient Service in the discharge summary or in the referral form and influenced by the outcome of the section 16 Review, the Community team did not accord urgency to Paul Ellis's case. It was waiting for more extreme behaviours than those that led to Paul Ellis's admission to the Inpatient Service.

· The responsiveness to the concerns of the family was timely, but misguided, because the community team did not have the relevant clinical information and was acting under a misapprehension as to its legal responsibility.

Conclusion to Term of Reference 1.7.2

Liaison with Police

· The Police responded appropriately and in a timely way to the family's concerns about Paul Ellis following his discharge from Tiaho Mai.

· The liaison between the Community Mental Health Team and the Community Constable was appropriate in the circumstances.

· Given that there were no signs or indications that Paul Ellis's behaviour or mental health condition was of serious concern or posed a serious danger to himself or others, the Police acted appropriately in dealing with the incidents they attended upon. Their assessments did not necessitate a formal contact with the Mental Health Services, in the circumstances.

Conclusion to Term of Reference 1.8

Consideration given to re-initiation of compulsory assessment and treatment under the Act at all stages after the section 16 Review hearing

1. The psychiatrist did give adequate and timely consideration to re-initiating the compulsory assessment and treatment immediately following the section 16 Review hearing and was influenced in his decision by:

· the improved clinical presentation of Paul Ellis

· the inability to satisfy the second limb of the statutory definition of mental disorder, namely that he was a danger to himself or others, or could not care for himself adequately

· Paul Ellis's willingness to take medication and to be treated voluntarily in the community

· the section 16 discharge of Paul Ellis from compulsory status one hour previously.

2. There was consideration given to the re-initiation of the compulsory assessment and treatment processes under the Act by the community team, but the Team was influenced in its decision not to take such action because:

· There was no clinical indication that the procedures should be re-initiated.

· The time was limited between receiving information about Paul Ellis's behaviours on 23-24 October and the tragedy which occurred on the night of 25th October.

· The decision to release Paul Ellis under section 16 became a benchmark by which Paul Ellis's behaviour was measured. His behaviour was no worse than prior to his admission to the Inpatient Service.

· The community team was acting under a misapprehension as to the legal liability of its members and there was reduced access to clinical guidance to rectify that view.

Conclusion to Term of Reference 1.9

Comment on any other matters relating to the operation of South Auckland Mental Health services which may have had an impact on the care delivered to Mr Ellis

1. The community team did not have access to information documented in the inpatient file and nor was there any adequate discharge summary completed at the time of discharge and no formal discharge process was undertaken. The problems to be addressed are as follows:

· One clinical file is needed with a system to monitor its effectiveness.

· Discharge summaries must be completed on the day of discharge.

· More detailed records of handover and meetings should occur with records needing to be incorporated into the clinical files.

· The implementation of the acute management clinical care pathway which identifies tasks, time-frames and responsibilities for managing an admission needs to be fully implemented.

· Transfer of information relating to a patient should be both verbal and written, where patients are being transferred or referred from one part of the service to another.

2. Duplicate prescription forms need to be introduced, to ensure that prescriptions are contained in a clinical file, being an exact duplicate of the medication actually prescribed for a patient at any particular time.

3. There is no legal requirement to inform the section 8A applicant of a patient's request for a section 16 interview and there was no process for staff to inform family or significant others about Mental Health Act proceedings.

4. The serious incident review process, which is held frequently in the South Auckland Mental Health Services has led to changes in practice that were evident at the time of this Inquiry.

5. There were significant problems highlighted in this Inquiry regarding resourcing and its relevance to the operation of South Auckland Mental Health Services which may have had an impact on the care delivered to Paul Ellis. They are:

· Inadequate Medical staffing

· Reduced Inpatient bed availability

· Reduced work force resources, including night-shift duty requirements and supervision

· Excess patient numbers

· Inadequate Funding.

Conclusions to Term of Reference 2

The Policy and Legal considerations of section 16 Mental Health Act Should there be any change?

1. Section 16 Mental Health Act should be amended to ensure that the Applicant under 8A be notified of the section 16 Review hearing, so s/he may be available, if the Judge wishes to consult further, as provided in Section 16(4).

2. The currently used section 8A ?Application for Assessment? form should be amended to include the telephone contact details of the Applicant, including day and night contact phone numbers on the form. The current form provides for the name and address only.

3. To ensure that the responsible clinician and secondary mental health worker can fulfil their statutory function under section 16, both the Judge and the Mental Health workers must ensure that before a section 16 review occurs, the Mental Health workers have undertaken their assessments and/or observations of the patient and, if not, the Review must be stood down or postponed to enable those relevant assessments and observations to occur.

Summary of Recommendations

Term of Reference 3

Clinical Staff Training

Doctors

· Responsible Clinicians require training in the role of an expert witness, in the use of hearsay and the ability to incorporate various sources of information into their opinion. They must understand the procedure at a Court hearing and their ability to decline to give an opinion if they have not yet assessed the patient.

· Training should be provided for foreign doctors, not only for local clinical management and prescribing patterns, but specific training and the procedures of the Mental Health Act, including training in Court procedures as above.

· Supervision, peer review and formal training will ensure that responsible clinicians develop a proper understanding of the use of the MHA.

· Registrar training schemes should incorporate the legal aspects of psychiatry into their curricula.

Role of Second Health Professional

· Training should be provided to health professionals performing the role of the second health professional to ensure that the consultation required under sections 16 and 18 MHA is meaningful.

· A health professional with knowledge of the patient should be available to attend Review or CTO hearings to provide meaningful consultation.

Duly Authorised Officers

· Specific training for DAOs should be provided to ensure that they have adequate information to make recommendations on committal and the reinstitution of the MHA processes where a patient has been discharged from a Review hearing into the community. The advice and information to be given to an involved family of the patient should be included as part of the training.

· The DAOs should have regular attendance at meetings with the DAMHS or under the DAMHS direction, so that aspects of legal liability or clinical problems can be discussed and aired.

All Mental Health Workers

· All mental health workers need to demonstrate processes of engagement with patients and their families/whanau, irrespective of their status under the MHA, as part of good clinical practice. They must be able to balance the individual privacy rights of the patient and the requirements of the MHA with regard to the degree of consent to treatment and the extent of involvement of family/whanau.

· Services must ensure that all mental health workers understand the criteria for compulsory assessment and treatment, as well as the ability to recommit an individual following release from compulsory status.

Clinical Documentation

· Mental Health services should institute a ?one patient, one file? system and adopt one clinical record per patient, either by a physical paper or a computer based file.

· To improve standards of clinical documentation, South Auckland Health should provide training, audit and performance management.

· South Auckland Health should ensure :

(i) Contact details of carers, family members, significant others and the patient's GP should be recorded in the front sheet of every clinical record as part of initial contact and be regularly updated.

(ii) Records of all contacts and phone calls relating to the care of a patient should be made in the clinical file, including when the recipient is not available.

Planning and coordination

Treatment Plans.

· South Auckland Health should ensure procedures are established for development and regular review of plans within each service.

· All patients should have some form of current clinical plan documented in their file.

· Information should be provided to patients and families/whanau that enhance their understanding and involvement in the planning processes.

· The role and responsibilities of the key workers (or other equivalent) need to be clearly detailed.

Discharge Planning Meetings.

· Discharge planning meetings should occur with all relevant services and community supports. The planning should include all relevant people involved in the ongoing care of a patient and incorporate an expected discharge date, proposed treatment options, clarification of roles and expectations, and task allocation.

· The clinical record should document those present at any planning or discharge meeting and the key issues and decisions arising out of the planning process.

· Task responsibilities to be clearly defined and allocated to staff with expertise to complete the task.

· Management plans, including those in discharge plans, should be clearly set out in writing and accessible to relevant staff.

· Some form of coordinated discharge process needs to be put in place for an unplanned/unexpected discharge, with roles identified to complete this process within the team.

· Regular clinical liaison among appropriate staff in the inpatient and outpatient services should occur to enhance continuity of care and identify gaps in information about a patient.

Referral and Transfer of information

· Relevant referral forms must be available, completed comprehensively and sent promptly.

· A written discharge summary should be sent to relevant services within 24 hours of discharge from any service.

· Medication information must be specifically included in the discharge summary. A duplicate prescription record will ensure that copies of prescriptions are kept within the clinical record.

Identification and addressing substance-abuse issues within the mental health sector

· Mental health workers need to have knowledge of clinical presentations and interventions for substance-abuse, as well as access to specialist consultation and support.

Mental Health units should ensure that systems are established, to identify co-morbid substance-use with the incorporation of the available range of screening tools, as part of the admission assessment.

Mental health workers must be trained in interventions appropriate to managing substance-abuse problems in patients they work with.

Mental health workers should be trained to advise patients about accessing specialist alcohol and drug services.

Amendment to Mental Health Act forms

Clinical Report Form

The clinical report form currently used by South Auckland Health should be amended to ensure that sufficient space is provided, to include detail and reasons in respect of the two limbs of the definition of ?mental disorder? are provided.

Clinical accountabilities and staff supports Role descriptions

Role descriptions within the Mental Health services must be clear and specific, and contain explicit tasks with measurable objectives, to ensure that individual employees can work towards them on a regular basis.

Clinical Supervision for all clinical staff

Staff must be able to access a supervisor when clinically appropriate and attendance by staff at supervision should be regularly monitored.

Performance Management System

Consistent implementation of a performance management system should promote discussion between clinicians and managers to clarify areas of job uncertainty and review staff members practice according to the expected objectives of their job description.

Requirements for training, supervision and ongoing professional development at both a core business and specialist level needs to be regularly monitored, including the incorporation of training into practice.

Inadequate resources

Adequate resources must be available to enable Mental Health services to provide adequate staffing and bed availability for patients, including an adequate and safe in-patient service.

Staff retention and recruitment are a necessary part of a proper functioning Mental Health service and adequate resources must be made available to employ and develop a better workforce in order to provide continuity of care and experience within a service.

Staff members should have access to regular supervision.

The allocation of staff must be appropriate for the work-load and to reduce inequality among the respective Mental Health teams.

Adequate funding is required for South Auckland Health to meet the recommendations of The Blueprint for Mental Health Services in New Zealand (Ministry of Health : 1998).

Legislative Amendment to provide Appeals by medical practitioners

The Mental Health Act should be amended to provide a right of appeal to a responsible clinician and a Mental Health professional where they are of the opinion that a patient should not be discharged under section 16 because it is adverse to the patient's health or constitutes a serious danger to the health or safety of that person or of others.

Inquiry under s95 of the Mental Health (Compulsory Assessment and Treatment) Act 1992

Terms of Reference

1. To inquire into the adequacy and timeliness of services provided to Paul Ellis and his family by the South Auckland Mental Health Services in October 2001, and communication and liaison with other agencies such as courts and Police providing emergency and justice services, including:

1.1 - community assessment processes prior to hospital admission

1.2 - assessment on admission, including any factors which may have compromised this

1.3 - communication about the scheduling of, involvement of family members in and information required for the s16 review hearing, and presentation of opinion and evidence at that hearing

1.4 - assessment and advice immediately after the s16 review hearing, the decision to initiate treatment as an outpatient, and recommendations made for treatment and re-assessment in the community

1.5 - communication and coordination between the in-patient and community services

1.6 - community treatment, re-assessment and follow-up, including whether this was sufficiently assertive

1.7 - responsiveness to the concerns of the family and liaison with other emergency service agencies such as Police

1.8 - consideration given to re-initiation of compulsory assessment and treatment under the Act at all stages after the s16 review hearing;

1.9 - and to make comment on any other relevant matters relating to the operation of the South Auckland Mental Health Services which may have had an impact on the care delivered to Mr Ellis.

2. To consider whether changes in service provision or in policy or legal frameworks should be instituted, including consideration of:

2.1 - the time period between admission and review under s16

2.2 - persons who should be notified of and given the opportunity to be heard in a review under s16

2.3 - minimum notification period for a s16 review hearing.

3. To recommend any actions which you consider necessary to improve provision of mental health services either in South Auckland or nationally, and to make any other recommendations which arise from the inquiry.

ENDS

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