Coroner adds to hospital critics

Coroner Garry Evans. File Photo / Herald on Sunday

A coroner reporting on two deaths has criticised central Auckland's psychiatric hospital, Te Whetu Tawera, for allowing a complex and high-risk patient to lock herself in her bedroom.

Garry Evans says Auckland District Health Board patients Kirsten Biggs, 39, and Vladimir Urlich, 36, died by suicide.

Ms Biggs died in Auckland City Hospital after an incident at the nearby Te Whetu Tawera unit in Grafton in June 2008. Mr Urlich died at his apartment complex in Emily Place in November 2007.

The mode of suicide and several staff members' names are suppressed.

Mr Evans said that "certainly in retrospect" Ms Biggs should have been put in category B under the board policy for increased observation, requiring a patient to be kept within sight of staff at all times. Instead she was in category C, requiring frequent visual contact - every 10 to 20 minutes or via four period checks per hour.

"... it was most unusual to place a patient under increased observation in the ward in which Ms Biggs was cared for," Mr Evans says.

"This fact would appear to be linked to the laissez-faire ethos shown by the evidence to have permeated the unit at the material time. [A nurse who cared for Ms Biggs] was necessarily caught up in that ethos."

Mr Urlich's death was one of six cases that led the health board and the Health Ministry in 2007 to order an external review of Te Whetu Tawera.

The four cases were a suicide and an apparent suicide at the unit, the death of a patient in its intensive care section, and the killing of Colin Edward Moyle by a patient - who was later found not guilty of murder by reason of insanity - after the patient was discharged from the unit.

The reviewers, including Dunedin psychiatrist Dr Stephanie du Fresne, made harsh criticisms of Te Whetu Tawera in a report later partially released by the board.

The unit's clinical director, Dr Greg Finucane, said yesterday changes had been made because of Ms Biggs' death. Improvements had been made to the observation policy, management of clinical notes and patient hand-over processes, and the unit now had more intensive care beds.

VLADIMIR IVAN URLICH

Found dead in a courtyard of his apartment, Tower Hill, in Emily Place in November 2007, aged 36.

Mr Urlich had borderline personality disorder, possibly bipolar affective disorder, drug and alcohol problems and paranoid psychosis.

At the time of his death, he was on a compulsory community treatment order and had been a voluntary inpatient at Te Whetu Tawera.

Coroner Garry Evans said there had been insufficient medical reassessment of Mr Urlich, a patient at high risk of harming himself, after his admission to the unit.

ANITA KIRSTEN BIGGS

Died, aged 39, in Auckland City Hospital's critical care department in June 2008, the day after a self-harm incident at the nearby Te Whetu Tawera unit, where she was a voluntary inpatient.

Ms Biggs, who was a mother, had what was described as a "chronic longing to die". She had made many attempts to take her own life.

She had suffered from anorexia nervosa as a teenager. She had major depression, but this diagnosis was progressively overtaken by one of borderline personality disorder.

When assessed on June 9, 2008, she talked of having contemplated a different form of suicide - the one she soon used - than those she had considered previously.