Coordinated Care Essential To Providing An Effective Mental Health Response

Deputy Health and Disability Commissioner Dr Vanessa Caldwell today released a report finding a district health board (DHB) and a mental health and addiction advocacy and peer support service (the service operating a mental health pilot project), in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failures to coordinate care that led to delay and a lack of appropriate follow-up.

The mental health pilot project had been established by the DHB as a single point of entry for all mental health services in the region, and was designed with a Te Ao Māori framework. The DHB and the service worked in partnership in delivering the pilot project’s services.

A man in his twenties had a mental health assessment at the DHB by a registered nurse (the nurse). Despite being assessed as "low risk", he was urgently referred to the project. Dr Caldwell was critical that the nurse did not document important details of the comprehensive assessment adequately, and that the urgency of the referral and the assessment of low risk were confusing.

"Although I accept that the use of the term ‘low risk’ was still being used by some practitioners at the time of this assessment, I understand that this approach of trying to predict future self-harm causes confusion and has little to no validity, and, as such, I have asked the Ministry of Health to give guidance to providers to cease using this approach," said Dr Caldwell.

Dr Caldwell commended the intention behind the pilot project in adopting a Te Ao Māori framework to meet the needs of the local community. However she was critical of its implementation.

"The transition to the pilot project was inadequate and there were delays in responding to the urgent referral," said Dr Caldwell.

Dr Caldwell considered that there was a significant gap in guidance about who had responsibility for the transition of consumers to the pilot project. There was no consensus across services on what an "urgent referral" meant, and there was a disconnect between the DHB and the service regarding expectations for the referrer to maintain contact with the case, and inadequate follow-up when the man could not be contacted.

"The outcome of the man’s mental health assessment was an urgent referral to the pilot project, however there were different views on what this meant.

"I am critical of this lack of clarity and consensus, which was compounded by the lack of consensus in the policies between the DHB and the service, with neither entity holding the same understanding of an urgent referral," said Dr Caldwell.

Dr Caldwell recommended that the DHB review and replace the risk prediction process with risk management and safety planning protocols; ensure that clinical assessments include clinicians’ reasoning for admission decisions and use of the Mental Health Act; clarify who holds clinical responsibility for the patient’s care at the point of referral and escalation; develop a more formal system of recording the content of telephone conversations; provide training on compassionate communication; report back to HDC on the actions taken and any outstanding issues from the recommendations in the Serious Incident Review; and provide a written apology to the man’s whānau.

She recommended that the service collaborate with the DHB on reporting to HDC on the recommendations in the Serious Incident Review that relate to the pilot project, and provide a written apology to the man’s whānau.

Dr Caldwell also recommended that the nurse undertake training on keeping clear and accurate patient records.

Dr Caldwell has asked the Ministry of Health to request that providers are advised to cease using risk prediction in determining self-harm, and to adopt a consistent approach to risk management and safety planning.

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