The man received care from two psychiatrists and the crisis contact centre, all of which were part of the CMHT. He was also receiving care from his general practitioner, who was not subject to the investigation.
Despite increased contact with the CMHT, by both the man and his parents, the HDC found there were a number of shortcomings in the documentation kept by staff and in the communication from one of the psychiatrists to the man’s general practitioner, resulting in inconsistent approaches to his care.
The decision says early on in a series of events, the man’s mother contacted the DHB’s mental health team concerned about her son’s mental state. Six days later, she and her son attended an appointment with his psychiatrist, identified as Dr B.
Appointments with this psychiatrist typically occurred monthly, while the man was visited by his mental health care manager weekly.
At this appointment, she raised concerns about her son’s medication and mental state. “Months went by and nothing was done,” the mother told the HDC, saying she felt her concerns weren’t taken seriously by the doctor.
When the psychiatrist wrote to a colleague for a second opinion, he noted the man was doing “reasonably well given his circumstances”.
A month later, the man himself rang the mental health team asking for a reduction in his medication. He said he would refuse all medication if his dose wasn’t reduced.
Dr B approved the reduction, but did not inform the man’s GP who was also closely involved in his care.
Over the following two months, the man contacted the mental health crisis team frequently. He later had another appointment with Dr B, who documented the care plan was “re-framing and positive thinking”.
Eventually, a medically-qualified family friend emailed Dr B with concerns about the man and his medication. The doctor told the woman changing medication would not address the man’s underlying issues.
A month later, the man had an appointment with his GP. He said he no longer wanted to see Dr B. The GP prescribed an antidepressant and sent another referral to the mental health team to request a reassessment, noting the man was becoming more depressed.
The GP also noted communication from the mental health team had been poor.
The DHB later alleged the GP “undermined the deliberate approach maintained by Dr B” over the previous five years.
The man eventually met with a new temporary psychiatrist, Dr D. The exact date the man’s care was transferred was not recorded. Dr D said the man’s symptoms appeared to be in line with a personality disorder.
Two days later, the man-made another call to the crisis team saying he was suicidal. There was no record a mental state examination was undertaken. An ambulance was called to take the man to the emergency department.
Another appointment with the new psychiatrist was held a month later. The doctor deemed he no longer needed to see the man, but the man mistakenly understood he was being discharged from the mental health services. Distraught, he told his parents who contacted the DHB to arrange a meeting.
Before the meeting was held, the man was rushed to hospital after harming himself. Again, the notes did not record a “clear exploration” of the man’s symptoms.
At the meeting with clinical staff and the man’s family, it was decided the focus should be on helping the man in ways other than medication. The man got upset in this meeting and walked out.
Days later, the man’s mother became concerned and contacted the mental health team. The man’s care manager visited his home, discovering he had suffered injuries, suspected to be self-inflicted.
He passed away the following morning. The man’s mother later complained to the HDC.
After the HDC’s investigation, Dr B admitted he should have spoken more frequently with the man’s GP. He agreed to write an apology letter to the man’s family.
Deputy Commissioner Vanessa Caldwell said with mental health care of this nature, it is fundamental that all parties maintain robust documentation and have open and clear communication with other providers.
“On a number of occasions, various staff at the DHB kept poor clinical documentation,” she said. “I consider that the pattern of poor record-keeping highlights deficiencies at an organisational level, for which ultimately the DHB is accountable.”
She also raised concerns about a lack of a “clear actionable plan” for the man’s care after the family meeting. She found the DHB was in breach of the Code of Health and Disability Services Consumers’ Rights.
She recommended Te Whatu Ora provide a written apology to the man’s family, and provide evidence that it has updated its internal policies to ensure adequate communication between providers and provided copies of the decision to all psychiatrists in the interests of education.
Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.
