Warning: This story contains material that may upset some people.
The Health and Disability Commissioner (HDC) has found the care provided by health providers in Wellington to a man suffering from mental distress fell short, "resulting in inconsistent approaches" to his care.
In a report released on Monday, the HDC said Te Whatu Ora Capital, Coast and Hutt Valley and a psychiatrist at the Community Mental Health Team (CMHT) breached the Code of Health and Disability Services Consumers' Right when the man, in his 60s, was in their care.
HDC said the man had been under CMHT's care for a number of years and died in hospital after harming himself, after a period that his parents saw "his deteriorating mental state, which included agitation, panic attacks, depression and suicidal ideation".
In a statement, HDC said the man received care from two psychiatrists and the crisis contact centre, which is part of the CMHT - run by the Mental Health, Addiction and Intellectual Disability Service (MHAID).
The HDC said the man was also receiving care from his GP, who wasn't subject to the investigation.
It said there was increased contact with CMHT by the man and his parents "due to concerns about the man's mental state, including frequent phone calls with the crisis contact centre and appointments with two psychiatrists"
But said there were "a number of shortcomings" in the documentation by staff in the CMHT, in the communication from one of the psychiatrists to the man's GP, which the HDC said resulted in " inconsistent approaches to the man's care"
It added a whānau meeting was arranged to discuss the ongoing management of the man's care, which left him feeling "distressed about being discharged from the care of the CMHT".
Deputy Health and Disability Commissioner Dr Vanessa Caldwell, found Te Whatu Ora Capital, Coast and Hutt Valley in breach of Right 4(5) of the Code, which gives consumers the right to cooperate among providers to ensure quality and continuity of services.
Dr Caldwell said on a number of occasions staff at CMHT and the contact centre kept poor records of the man's contact with the services.
"In my view, the inadequate documentation kept by the contact centre and CMHT contributed to a distinct lack of clarity and action amongst teams about changes in the man's care, treatment plans, and expectations, including the possibility of the re-emergence of symptoms," she said.
"This culminated in the collective failure by several clinicians at various points of crisis contact and at the whānau meeting to offer appropriate support to the man following his increasing distress which was entirely predictable."
Dr Caldwell found the psychiatrist breached Right 4(5) of the Code for the lack of cooperation with the man's general practitioner to ensure quality and continuity of care.
"I am concerned about the psychiatrist's lack of engagement with the man's GP, particularly regarding changes in the man's treatment and the reduction of antipsychotic medication."
Dr Caldwell recommended Te Whatu Ora Capital Coast and Hutt Valley include providing a written apology to the man's whānau for the failings identified.
HDC said Te Whatu Ora has made a number of changes in response to the report, which includes MHAIDS have implemented two of the recommendations, including reviewing the Whānau/Family Participation policy to ensure care, transition planning and exit processes incorporate practices that support collaborative planning and outcomes.
