Inadequate monitoring in inpatient mental health unit

Deputy Health and Disability Commissioner Kevin Allan today released a report finding Waitemata DHB in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to properly monitor a young man who was admitted under the Mental Health Act 1992.

The man was admitted to a psychiatric intensive care unit ("the unit") at Waitemata DHB, with substance-induced psychosis. He was admitted for compulsory assessment and treatment under the Mental Health Act. Because he was a risk to himself and others, he was placed on 15-minute observations. He was frustrated at being detained in hospital, and also at risk of going absent without leave. Five days later, when the man’s sister came to visit, staff were not able to locate him. It became evident that he had left the building up to an hour before his sister’s arrival, but it was unclear exactly when. It was thought likely that he left through an unmonitored enclosed outdoor area in the unit.

Mr Allan found there was inadequate monitoring in the unit. There was confusion about who was responsible for making the observations, and this was compounded by an inadequate handover. Mr Allan found that although the relevant policy required a staff member to be allocated as responsible for carrying out observations, this did not occur in practice. He also found there was no comprehensive policy about access to the enclosed outdoor area in the unit.

Mr Allan was critical of Waitemata DHB. He stated "adequate systems and procedures are necessary to support staff in their duties and to facilitate the delivery of safe and appropriate care. It falls on the WDHB as the service provider, to have in place clear policies that guide individual staff in the operation of the unit, and to ensure compliance with these policies."

Mr Allan recommended that Waitemata DHB provide a written apology to the man and his family. He also recommended the DHB amend its therapeutic observations policy to improve guidance about the handover process, incorporating the expectation that the observation sheets are signed when the observation is carried out; consider using a more comprehensive observation form that reflects the health issues and needs of the individual at that time; and audit compliance with its newly implemented policy about access to the enclosed outdoor area in the unit. Waitemata DHB has already undertaken an audit of 15-minute observations.

https://www.hdc.org.nz/decisions/search-decisions/2019/16hdc01402/

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