Changes made after schizophrenic woman's death - DHB

Auckland City Hospital. Photo / Sarah Ivey

Changes have been made to how mental health units are run following the death of a patient three years ago, the Auckland District Health Board (ADHB) says.

Maria Eve Richardson, 60, was found dead in Auckland City Hospital's mental health unit on July 24, 2007. An autopsy found she died from cardiac dysrhythmia.

An inquest found that the night before she died, Ms Richardson's blood tests had shown grossly elevated free thyroxine levels, which Coroner Garry Evans later ruled might have contributed to her death.

An on-call medical registrar was called to assess the blood tests by telephone, and advised that Ms Richardson did not require transfer to a medical ward.

"In retrospect, Ms Richardson should have been physically examined by the medical registrar," Mr Evans said in his findings, released today.

In a report to Mr Evans, Debbie Antcliff, then ADHB's director of area mental health services, said mental health units had difficulty accessing input from general medicine for medically compromised patients and recommended a greater input from medical teams to the units.

Mr Evans repeated the recommendation in his ruling, saying the DHB should "take the necessary steps immediately to ensure that patients in its mental health units receive at all times the same standard of medical care as patients in other wards and units".

In a statement today, ADHB director of mental health services Clive Bensemann said a number of improvements had been made to the board's systems and procedures following Ms Richardson's death.

"This is a sad situation and we regret that Maria did not receive better care in our system," Dr Bensemann said.

"We recognise there were failings within the service and Maria's death has prompted improvements to many of our procedures. In the three years since Maria's death, we have made significant progress in implementing systemic changes to the way we care for our mental health inpatients."

The policy regarding how patients with physical health problems were monitored had been addressed, and a nurse specialising in physical health had been appointed to help improve nursing care for general medical problems.

- NZPA