KEY POINTS:
Central Auckland's mental health service is apologising to families and being restructured after a series of patient deaths and an alleged murder.
These moves follow harsh criticism by external reviewers of the service's mismanagement of the risks posed by some complex patients.
The review panel said the incidents occurred "because of a lack of appropriate leadership in medicine, nursing and management" at the Auckland District Health Board's acute mental health inpatient unit near Auckland City Hospital, Te Whetu Tawera.
"These difficulties have been brought to the attention of senior clinical management of mental health services for ADHB over some years, and no effective action has been taken," said the reviewers, psychiatrist Dr Stephanie du Fresne, nurse Joan Chettleburgh and patient representative Brian Vickers.
The review, released in part yesterday, was commissioned by the board and the Ministry of Health because of four deaths last year.
The reviewers say those four cases, and two others they were asked to consider, "show evidence of unacceptably poor clinical judgment and practice by some medical and nursing staff".
The four cases are also mentioned in documents released on Wednesday, when the Government-appointed Quality Improvement Committee revealed that 40 patients had died from preventable events at health boards nationally in the last financial year.
The mental health review follows a decades-long line of highly critical reviews and inquiries into the Auckland region's mental health services, but differs in that it was initiated internally after problems were suspected.
In a case involving Matthew Ahlquist, the reviewers say intake staff on his final admission failed to take note of his threat to kill, there was a failure to respond with assertive treatment and containment after he assaulted his parents and he was discharged with no clear follow-up or accommodation arranged.
The reviewers suggest the unit got the balance wrong between the "recovery model" - which aims to help patients regain control of their lives and for which the unit has attracted praise - and risk management.
The recovery focus, minimising use of force and restraint, and other policies had been "subject to distortion and to being thwarted wholly or in part", the report said, and there was a culture of bullying among staff. The board management accepted there had been failings and was in the process of offering its apologies to the families involved, said the general manager of mental health services, Fionnagh Dougan.
When asked if individual staff would be disciplined, she said those referred to in the report had been given an opportunity to respond and she could not comment before that process had been completed.
Changes to the unit include adding a nurse adviser to its current leadership team; having individual risk management strategies; boosting patient observation; and making the community mental health teams more assertive in reaching out to patients.
Ms Dougan said the mental health service was trying to improve safety.
"There is never going to be a 100 per cent guarantee that there will not be incidents in the community."
FOUR TRAGEDIES
* Matthew Ahlquist allegedly murdered Colin Edward Moyle in Sandringham after being discharged from Te Whetu Tawera. Ahlquist, accused of bludgeoning Mr Moyle and setting him on fire, is before the court and a patient of the Mason Clinic.
* The suicide of a man in an open ward at the unit.
* The apparent suicide of a man at the unit.
* The death of a patient at night following admission to its intensive care unit.
