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Manu Case Complex, Difficult

A report into the mental health care provided to Johnny Manu prior to the fatal stabbing of ACC worker Janet Pike, highlights the difficulty of caring for people with several psychiatric conditions, some of which are not necessarily "treatable", the Ministry of Health says.

The Ministry extends its sympathy to the family of Janet Pike.

Deputy Director of Mental Health, Dr Anthony Duncan, said the report highlights other issues, including resourcing, communication and the need for better links between mental health and justice services.

He said it was also important to note that Mr Manu had other needs which were not the sole responsibility of mental health services, that were not adequately met, such as housing and social issues.

Mr Manu, currently serving a life sentence after being found guilty of fatally stabbing Janet Pike in June 1999, has been diagnosed with chronic residual schizophrenia, complicated by an antisocial personality disorder, itinerant lifestyle and abuse of procyclidine, a drug prescribed to treat the side effects of his anti-psychotic medication.

Dr Duncan says the report commissioned from District Inspector for Mental Health Phillip Recordon made it clear that while Mr Manu's mental illness had been adequately treated, his other problems had not.

"It's notable that all the clinicians involved in Mr Manu's care agreed that his history of offending, including assaults and threatening behaviour, stemmed primarily from his personality disorder rather than his mental illness.

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"Most mental illness can be successfully managed through medication. However associated problems such as anger management and impulse control, which stem from a personality disorder, cannot be treated with medication, as there is no medicine which works.

"However, there are techniques which can be used to help the person control their anger and related difficulties, providing they accept they have a personality problem and have a desire to overcome it," Dr Duncan said.

"In the absence of a desire to change the behaviour, the only "treatment" is to manage the person and the risks they present to themselves or to others. That was attempted here, but with varied success."

Dr Duncan said, that in each case there are various situations which may "trigger" the person to behave aggressively.

"To manage any person like this successfully requires a high level of communication between all agencies."

The report says that Mr Manu's history made it clear that violence could be, and had been triggered by dealings with institutions where money was involved. However not all providers were aware of this, and if they had been, they may have responded differently to the problems Mr Manu had prior to the attack on Janet Pike.

"Unfortunately the wisdom of hindsight will not bring any comfort to Janet Pike's family who will inevitably feel the system let them down. Many of those in the mental health sector, including the Ministry of Health have personally expressed their sorrow for what has occurred.

Dr Duncan said that the Government has recognised that there are gaps and has increasing funding towards the Mental Health Blueprint.

"The mental health system is constantly evolving and we are continually looking at ways to improve."

Dr Duncan said it is the nature of dealing with people with a mental illness that there will always be individuals considered at risk of harming themselves or others, however he said it was important that this was seen in terms of the whole of society.

"Mental illness can affect anyone. In some cases the identified risk will relate purely to the persons mental illness, in other cases purely to their personality difficulties or substance abuse, and in others it is a combination of these."

The vast majority of people with a mental illness are able to live comfortably in the community and manage their condition through their own efforts and the support of mental health teams.

"Those who are considered at greater risk are managed and treated in a way to best manage both their condition and the risk they pose to themselves or others.

"These individuals undergo a risk assessment process to ensure those who required it, receive appropriate and careful management."

Dr Duncan said a number of initiatives were underway to improve the mental health system.

The mental health system does reflect the values of society. In most instances the freedoms and restraints on the general public, also apply to those with a mental illness.

"Work is underway to develop a "one file per patient" system to improve the transfer and accuracy of information within each Hospital and Health Service (HHS). We also intend to ensure that HHSs have reliable systems in place for ensuring the prompt and accurate transfer of information about high risk clients between HHSs and non government organisations when they move between providers."

It is intended that the information about high risk individuals would effectively follow them regardless of which agency may be providing their care.

"We will be balancing the need to provide appropriate alerts to services and at the same time protecting the privacy of people's information. In the vast majority of cases, information will be transferred only with the clients consent. However, services have to reserve the right to transfer information about high risk cases if it is deemed necessary. "

"The Ministry is currently reviewing forensic services, including the transfer of information and ways to improve interaction and communication between Corrections and mental health services.

"We will be working with the Department of Corrections and caregivers to discuss long term rehabilitation, and better provision of a "wrap around" service which would combine the clinical care as well as housing requirements. Models for this are also being considered for children and youth, where a number of agencies are involved in care, education and treatment."

"We recognise the importance of providing culturally appropriate services and a Pacific Island mental health team has been set up in South Auckland where Pacific Island People make up 17 percent of the population."


For more information contact: Selina Gentry, Media Advisor, ph: 04-496-2483 or 025-277-5411 Internet address: http://www.moh.govt.nz/media.html

Dr David Chaplow Director Regional Forensic Psychiatric Services 09 849 7789 / 025 956 189

Barbara Disley Chair Mental Health Commission 04 474 8919 / 025 249 2405

Background Information

Terms of reference were to inquire into: the adequacy and appropriateness of care and treatment in hospitals and services as defined by the Mental Health (Compulsory Assessment and Treatment Act) 1992 given to Manu in respect of his condition and diagnosis, and in particular whether: a) the degree of risk posed by Mr Manu, to himself and/or to others was adequately and appropriately assessed and managed: b) all services ensured that an appropriate process was in place for reviewing risk, care, and treatment and took proper steps to ensure that this process was followed; c) the impact of Mr Manu's substance abuse and any other co-existing conditions were appropriately considered by all services; d) any concerns expressed by caregivers of Mr Manu's family were communicated to and properly and appropriately considered by clinicians responsible for the assessment of Mr Manu's condition and any management plan; e) Mr Manu's care and treatment was co-ordinated between services and agencies; 2 the adequacy of communication between hospital and services, as defined by the Act, and between caregivers/whanau and hospital/services to ensure that those clinicians and carers responsible for Mr Manu's care and treatment were appropriately informed and to ensure that such care and treatment was co-ordinated 3 responsibility and accountability for the care and treatment of Mr Manu and whether this was clearly identified 4 whether compulsory assessment and treatment under the Act was considered and the appropriateness of treating Mr Manu either as a voluntary patient or under a compulsory treatment order 5 the extent to which services addressed the particular cultural needs of Mr Manu and incorporated this into his overall care and treatment 6 any other matters related to, or impinging on the care and treatment of Mr Manu which may have wider implications for the use of the Mental Health Act or the contracting and provision of services to individuals with similar conditions 7 To recommend what steps, if any should be taken to deal with any matters which may arise from your inquiry.

Recommendations from the report:

1. We recommend that the proposed Memorandum of (patient) Transfer covering the Auckland area should be extended to cover Northland Waikato Thames Valley Coromandel, is finalised and signed off without delay.

2. We recommend that in recognition of the importance of accurate, complete speedy transfer of client information, there should be developed computer hardware and communication systems enabling areas to 'talk' with each other ? national guidelines. The 3 Auckland HHS', with appropriate HFA funding, should move, forthwith, to the development of compatible communication systems.

3. We recommend the development, nationality, of minimum patient data to be automatically transferred when patients move from one HHS area to another. This data should include an up to date:

(i) risk assessment and (ii) care management plan.

4. We recommend that National Mental Health Privacy guidelines should be further developed along the lines suggested in this report. All Mental Health workers should be advised that accurate up to date information of past offending is relevant, is a matter of public record, should be given to those involved with client care. Guidelines regarding sharing information between HHS' services, caregivers, whanau and boarding houses must be developed. The Privacy Commissioner's guidelines on Mental Health should be supplied to all acute or rehabilitation mental health units throughout the country.

5. We recommend that culturally appropriate assessments be initiated and carried out at an early stage of consumer contact with MHS. The HFA should ensure funding is at appropriate levels to ensure appropriate people to carry out the assessments are available especially in South Auckland.

6. The current line drawn between Prison and Mental Health Services is artificial. We recommend that there be a closer interaction between Corrections and Mental Health Services to ensure joint responsibility for people with mental health needs while they are in prison. It was beyond our brief (and not directly relevant to Johnny Manu's care) to consider the benefits or otherwise of a law change which would allow compulsory treatment for those serving prison sentences.

7. We recommend that the basis of the provision of Community Mental Health services alters (nationally) so that health funding money 'follows' and is 'attached to' clients in the community (flexi funding/wrap around) based on the needs of clients ensuring individual needs are met as opposed to the current split between the provision of clinical needs and accommodation/care needs.

8. We recommend that in the interim (ie. while recommendation 7 is implemented), the HFA increases, nationally, and particularly in the Auckland area, the flexi funding budget so as to ensure support for high needs people in accommodation which is not adequately funded to provide an appropriate (for the individual) level of care.

9. We recommend that the HFA should negotiate contracts, forthwith, with the non contracted South Auckland providers currently caring for clients with a high level of need to ensure those needs are met. The 'ideal'/alternatives 'planned' by the HFA are not being developed as they should be and do not, in any event (as planned), take into account the realities of life in South Auckland (including the choice that the majority of clients have to live where they want to).

10. We recommend that the HFA, forthwith, fund and develop the existing MIT and ICT so as to provide effective multi-disciplinary teams 24 hours a day 7 days a week. We recommend that consideration be given to similar properly funded and area-appropriate Intensive Community Teams being developed nationally. We recommend that Intensive Care Team should have clear agreements on case loads which should be adhered to ensure they do their job.

11. We recommend that the HFA promptly redresses the imbalance of Mental Health Services in the Auckland area having regard to the South Auckland Report. The HFA recognises the imbalance and has plans to redress the imbalance, but change is taking far too long. The HFA must move promptly and effectively.

12. We recommend that it should be incumbent, on health agencies to provide information to any person or entity caring for a mental health consumer, where non provision may impact on a provider's ? carer's ability to care for an individual. The Manu case highlights that reliance on earlier psychiatric reports does not ensure that information is up to date or accurate. Original sources (Court records, police computer records, original files) must be accessed to ensure information and transfer of information is accurate, up to date, complete, relevant and "not misleading".

13. We recommend as part of the engagement process with a client, agencies should ensure that clients' views on the subject of information sharing are known and updated from time to time. These views should be recorded and referenced on files to make them easy to find (in the same way risk assessments, relapse plans are found). The files will record agreements on which people can receive information about a person and what information those people can receive. Along with that paper there should be a record of what the patient has been told regarding what other information would be shared, together with an, preferably signed, acknowledgement by the patient that he or she has been told what information will be disclosed to whom and that the client has been made aware of his or her rights to contact the Privacy Commissioner for further information or to make a complaint.

14. We recommend that the RFS in Auckland be adequately resourced to provide liaison services to link with community mental health teams in providing care in the community for people like Johnny Manu.

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