Emails reveal concerns in NZ's busiest emergency departments.
As the medical system faces being stretched again during a busy winter, documents reveal health workers at Auckland City Hospital's busy emergency department regularly face abusive behaviour and threats from mentally unwell patients, writes Sophie Trigger.
A health worker was punched in the face by a 62-year-old woman who had spent 21 hours in Auckland City Hospital's emergency department because there were no available beds in the mental health unit.
Another "extremely verbally abusive" patient told a hospital staff member, "I will remember your face and slit your throat, cut out your eyeballs and shoot you in the face."
Documents released under the Official Information Act have lifted the lid on security concerns at New Zealand's busiest emergency department last winter, many voiced by staff who work on the front line.
Hospital staff and managers are already concerned that with the approach of winter illnesses and Covid-19, hospital emergency departments will be unable to cope.
Emergency medicine specialist Dr Scott Orman wrote in an email last June that prolonged emergency department stays due to "under-resourcing and flawed models of care" were not uncommon for mental health patients. Patients could wait more than 12 hours to be seen by the urgent response service, an offsite community mental-health team that responded to patients "in a state of crisis".
"We believe that these delays contribute to behaviour escalating and everyone's safety being affected," he said.
In May last year, a hospital healthcare assistant was punched in the face by a psychotic patient. The 62-year-old woman had been in the emergency department for 21 hours because no beds were available in Te Whetu Tawera, the hospital's adult acute mental health unit.
The patient waited a total of 27 hours before being admitted after being assessed by an emergency department doctor as psychotic. She was referred for mental health review at 2.30pm that day and seen by the urgent response service at 6pm, which determined she needed to be seen by a doctor.
An overnight psych registrar eventually saw her at 4am the next day, more than 13 hours after being initially assessed and referred to a mental health doctor for review. The woman was placed under the Mental Health Act but remained in the emergency department because of the bed shortage in the mental health unit. With no mental health watch staff available either, she was supervised by a healthcare assistant in that department.
The woman was not admitted to the mental health unit until 4pm, in spite of "escalating" behaviour which culminated in the patient punching the health worker in the face. Security staff were then called to take over the watch. The healthcare assistant was asked to return to watch the same patient later that day to cover another staff member's break.
In another incident, in July last year, a patient who had undergone psychiatric assessment had to be restrained after threatening suicide and trying to leave the hospital. She was restrained by several security staff who were kicked, spat on and racially abused by the woman in the emergency department.
While the patient was restrained, discussions were held around her about options for her care - whether to take her to the police or sedate her because the patient was "taking up an ED bed for hours".
The writer of the email covering the incident also expressed concern that the restraint, while necessary for safety, had triggered the patient, who had a history of trauma.
"I feel the pts [patient] was restrained for an unnecessary amount of time while arguments were being made for her care," the email reads.
"I feel it was inappropriate to be forced to argue a pts right to remain in the department while pt was obviously distressed and causing distress to other pts and requiring intervention."
Internal Auckland District Health Board emails referred to a third incident in August in which a patient was "extremely verbally abusive".
The email, from the Workplace Violence and Aggression Prevention adviser, said a patient had threatened to slit the throat of a staff member, while maintaining eye contact with them.
The incident occurred on the first day of level 4 in the Auckland August Covid-19 outbreak, and the adviser referred to the increased levels of stress and anxiety staff were already under due to the stress of lockdown.
In response to questions about the delay in admitting mental health patients, Auckland District Health Board (DHB) director of provider services Mike Shepherd said there wasn't a specific target timeframe for admitting patients from ED into the service.
"Factors impacting the wait time to be admitted includes the capacity and demand of the service, which fluctuates day-to-day, and if a Mental Health Act assessment is required."
When a patient required an assessment under the Mental Health Act, this could take six hours or more, Shepherd said. A mental health nurse educator had been employed to work in the emergency department in response to the incident involving the woman who waited 27 hours to be admitted, he said.
The health board had also improved the handover information passed between specialists from the mental health service and the ED clinical team. Shepherd said the DHB continued to provide "extensive training in de-escalating aggressive behaviour" for adult ED clinical and healthcare security teams.
"Some of the specialist or emergency services we provide involve caring for vulnerable patients with sometimes challenging behaviours," he said.
It was important staff remained safe and supported while providing the best possible care to patients.
"When instances of violence or aggression against our staff do occur, we rally around to provide support to them, their whānau and their colleagues."
Staff were encouraged to report any incident so measures could be put in place to minimise the risk of a similar problem happening again.
Emergency departments around the country have been under pressure over the past year, with an outbreak of respiratory illness (RSV) overwhelming some hospitals even before the outbreak of the Delta coronavirus variant in the community last August.
Security were called to Auckland City Hospital's emergency department 260 times over the winter months last year, including 88 times in June, 95 in July, and 77 in August. On June 30, security staff were called nine times in 24 hours.
An audit into Christchurch emergency departments, released this month, found violence and aggression towards staff were not improving.
Published in the New Zealand Medical Journal, the report found verbal abuse and threats toward staff accounted for 69 per cent of all reports.
Incidents involving physical threats or assault made up 20 per cent.
Patients were usually the aggressor, with the report finding intoxication and mental illness were common contributing factors.
OIA (Official Information Act) data reveals security staff were called to Christchurch Hospital's emergency department a total of 85 times throughout the winter of 2021.
Wellington Hospital's emergency department operated at capacity throughout last winter, forcing Capital and Coast DHB to restrict visitors in June after the RSV outbreak.
Security in Wellington's emergency department increased in July after a provisional improvement notice was issued to management, formally tabling the health and safety concerns of nurses, which included overcrowding and feeling unsafe. A security breach in July last year involved an incident in which a patient stole a swipe card to exit the ED.
That month a group of junior Wellington doctors wrote to the Herald saying overcrowding and inadequate staffing in the emergency department were dangerous and posed significant risks to patient safety.
The Royal New Zealand College of General Practitioners medical director and Porirua GP Dr Bryan Betty said last month that he had concerns about the approaching winter.
"Every winter the system becomes stretched in New Zealand and [now] we're going to have Covid on top of it," Betty said.
"Covid is still going to be present, it's just going to be in peaks and troughs ... so that is a really mixed picture with a lot of potential demand on the system over the coming months.
"And I think that will be a real challenge for ambulances and EDs and hospital beds as well."
The 19-year-old disappeared without her wallet or mobile phone.