Warning: This story contains detail about mental health.
The Health and Disability Commissioner (HDC) has found Te Whatu Ora Counties Manukau breached the Code of Health and Disability Services Consumers' Right for the mental health services provided to a man who died of suspected suicide.
Counties Manukau District Health Board, now Te Whatu Ora Counties Manukau has been found in breach of "the code".
In a statement, HDC Dr Vanessa Caldwell said the man, in his thirties, was discharged from hospital where his care was intended to be transferred to a Te Whatu Ora district he had recently moved from.
But Dr Caldwell said the inadequate transfer of care from Te Whatu Ora Counites Manukau contributed to a delay "by the receiving service in establishing prompt therapeutic contact with the man."
"This was critical in light of the importance of follow-up after an inpatient admission."
Dr Caldwell found Te Whatu Ora Counites Manukau in breach of Right 4(1) for failing to provide services with reasonable care and skill.
The commissioner also found it breached Right 4(5) for the lack of co-operation between providers to "ensure quality and continuity of services".
"I consider that the onus was on Te Whatu Ora Counties Manukau as the transferring service to initiate and complete the transfer of the man’s care appropriately and within accepted guidelines," said Dr Caldwell.
Dr Caldwell said the National Transfer of Care Guidelines are "clear and concise", adding, in this case, the transfer did not meet the guidelines.
"I am critical that, particularly in the context of mental health care, more was not done by Te Whatu Ora Counties Manukau to transfer the man’s care safely. Overall, this led to a poor standard of care at the point of discharge."
Dr Caldwell said there were a number of concerns about Te Whatu Ora Counties Manukau's patient discharge and transfer process.
The commissioner found there was not adequate engagement with the man's support person, adding the man was allowed to travel alone on the day he was discharged without a person organised to go with him or pick him up.
"There was no aftercare plan issued to the man or his whānau which would have included emergency contact numbers or contact for the follow-up mental health team. There was a lack of timely communication initiated by Te Whatu Ora Counties Manukau to the receiving service and limited referral information was sent."
The commissioner's report highlighted the importance of an adequate system for the co-ordination of transfer for the patient's care from one region to another.
"And of ensuring that the handover is clear, and that the receiving region has accepted responsibility for the patient’s care. It also demonstrates the importance of providing timely and responsive services."
Some of Dr Caldwell's recommendations:
- Provide a written apology to the man’s family for the breaches of the Code.
- Provide HDC with an update on the changes implemented in response to these events, and report on any further changes that occurred following implementation.
- Consider developing a guideline about transport and supervision when a patient is to be transferred within Te Whatu Ora to a different district.
- Consider a review of the work pressures on staff in in-patient units.
The commissioner said since the event, Te Whatu Ora Counties Manukau has since worked to improve the assessment and management of risk through a comprehensive safety assessment.
It also has since increased the involvement of families in safety planning. It's been reviewing its existing discharge procedures, and said that the new procedures would include whānau participation in discharge planning.
Where to find help and support:
Shine (domestic violence) - 0508 744 633
Women's Refuge - 0800 733 843 (0800 REFUGE)
Need to Talk? - Call or text 1737
What's Up - 0800 WHATS UP (0800 942 8787)
Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
Youthline - 0800 376 633, text 234, email talk@youthline.co.nz or online chat
Samaritans - 0800 726 666
Depression Helpline - 0800 111 757
Suicide Crisis Helpline - 0508 828 865 (0508 TAUTOKO)
Shakti Community Council - 0800 742 584
