"There was no long-term care or responsibility taken by any of the specialist child and adolescent psychiatrists, clinical teams or caregivers, beyond their specific facilities," the report said. Though some specialists and institutions were praised for their efforts, none treated the patient properly for what was thought to be the root cause of the problems.
The Weekend Herald cannot detail those root problems for legal reasons.
The inquiry found "serious shortcomings" in the services provided to the patient and made 100 findings relating to continuity and consistency of care; clinical decision-making; clinical assessment, diagnosis and formulation; discharge and transfer planning; care and relapse prevention; communication between clinical teams; and CYF placement decisions.
The inquiry was ordered by the Ministry of Health's Director of Mental Health Dr John Crawshaw. In a letter attached to the report he expressed his concern over the patient's treatment, which was brought to his attention by district inspectors of mental health, lawyers advocating for patient rights.
"After careful consideration I have formally accepted the inquiry's findings and recommendations, some of which have significant implications for mental health services nationally," he wrote.
Last April international human rights expert Dr Sharon Shalev slammed New Zealand for having high seclusion rates among prisoners, children, mentally unwell and the intellectually disabled.
In 2016 a separate Herald investigation revealed the plight of Ashley Peacock, an intellectually disabled, autistic and mentally ill man who was kept in a tiny wing of the Tawhirimatea mental health unit at Porirua for five years, allowed outside for an average of 90 minutes a day. The investigation prompted his freedom.
Crawshaw said the inquiry in the new case made a number of recommendations to improve service provision to those with high and complex needs.
It's understood the report has been released to the DHBs involved in the case.
The inquiry recommendations included the need for:
• Changes to inpatient service provision to behaviourally disordered young people with high and complex needs;
• Community placements for these young people;
• Clinicians to use phenomenological criteria [perceptions, emotions and judgements] when assessing a person's suitability for assessment and treatment under the Mental Health Act;
• Assessments made from a longitudinal perspective for better management strategies;
• Clinicians in DHBs across the country to be able to access patient clinical records including mental health records;
• To assertively treat trauma
