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Mental Health Care Of Man In Inpatient Unit

Mental Health Commissioner Kevin Allan today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a man at a mental health inpatient unit.

The man, aged in his sixties, had a complex clinical background including a history of mental illness. When his condition deteriorated, he was admitted to the inpatient unit for diagnostic clarification. He was considered to be a moderate to high suicide risk.

The man was monitored over the weekend and no new concerns were noted until Sunday evening, when he became agitated and refused his medication. During the night, he barricaded himself in his room and began slamming the door repeatedly. He expressed a desire to leave the inpatient unit, and rang his sister and a friend for support.

Nursing staff undertook visual observations of the man during the night, but from 6.30am to 9.30am on Monday morning, no visual observations of the man were undertaken. A multidisciplinary meeting took place at 9am, during which the man’s sister’s concerns were conveyed and the man’s presentation was discussed.

At 9.30am, the man was found in his room following what was suspected to be an attempted suicide. He died four days later.

The Mental Health Commissioner found the DHB failed to transcribe possible diagnoses onto the man’s admission form accurately; to fully document a medical plan for care; or to document a nursing plan. The DHB also failed to ensure that the man’s room was checked for risk points; to complete hourly observations after 6.30am; and to escalate the man’s care when his condition deteriorated. The DHB did not have appropriate policies for observations and escalation of care.

"Given the context, I am concerned that, following admission, a nursing care plan was not developed for [the man], and that the documentation of his medical care plan was incomplete," said Mr Allan. "In addition, several staff demonstrated a lack of critical thinking about the care that [the man] required overnight, and a lack of initiative in addressing his deteriorating condition."

Mr Allan made a number of recommendations to the DHB, including that it finalise an escalation policy and provide evidence of training on this; audit staff compliance with hourly observation plans; assess and provide training on communication and teamwork skills within the team; conduct a review of risk assessments; and audit the efficacy of new handover and admission forms to ensure that the relevant information was captured. He also recommended that the DHB apologise to the man’s family for its breach of the Code, which the DHB has since done.

Mr Allan referred the DHB to the Director of Proceedings.

The full report for case 18HDC01087 can be found on the HDC website.

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