Southern DHB in breach after dad dies by suspected suicide

A dad in his 40s with a history of serious mental illness died by suspected suicide after being allow to leave hospital with no treatment plan. Photo / 123RF

A dad in his 40s with a history of serious mental illness died by suspected suicide after being allow to leave hospital for the day without an adequate treatment plan.

Mental Health Commissioner Kevin Allan has found the Southern DHB in breach of the Code of Health and Disability Services Consumers' Rights for failing to adequately plan treatment for the man.

Allan's investigation, published today, found the DHB failed to assess the man and his level of risk adequately - and criticised the fact there was no comprehensive treatment plan in place.

"The widespread failure of [the DHB's] medical and nursing staff to document discussions, decision-making, history, and treatment plans accurately during the period considered points to a culture of non-compliance with professional standards at [the DHB] at that time," Allan said in the report.

In 2017, the man was admitted to the inpatient mental health unit and was diagnosed with recurrent major depressive disorder, anxiety and cluster personality traits.

He'd had multiple admissions to inpatient psychiatric wards at two hospitals with low mood and suicidal ideation. He also had a history of deliberate self-harm and previous suicide attempts.

The report said there was no documentation as to his level of risk of suicide, or what observations were considered appropriate.

"SDHB stated that nursing staff initiated routine 30-minute observations on the man, but there is no documentation regarding how the decision was made."

After a week of staying in hospital, the psychiatrist felt the next step in assessing the man's ability to manage his emotions was to trial leaving the hospital for a night in a supported environment of his family.

The report said that the family were concerned by this due to the man's history of becoming very despondent and increasingly anxious about leaving hospital.

"Instead, the man went on day leave but this did not go well. The following day, he went missing from the ward, and was found to have died by apparent suicide."

Allan recommended that the DHB make changes to ensure a comprehensive formulation and treatment plan is developed with patients, and audit compliance with its changes.

He also advised that the DHB apologise to the man's family.

As a result of the investigation, the DHB is developing an electronic health record that will enable notes (including the two-yearly patient summary) to be maintained and available in an efficient manner.

The report said SDHB was also implementing a "document tree" that would be loaded onto its electronic filing system and populated with essential documents to provide a method of preparing, saving, and updating psychiatric history.

The psychiatrist said in the report that he continued to try to balance safety against the need to provide services that were not coercive, and that enhance patients' independence and minimise the risk of treatment-induced harms.

He said that he has undertaken more work around suicide assessment, and reading about the utility of different measures in quantifying risk, and how these add or do not add to clinical practice.

"[My] condolences remain with and family over the loss of their son, brother and father. I know [the man] achieved a lot in his life and believe that he had more to give and I am so sorry that did not happen," the doctor said in the report.

Where to get help:

• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• CASPER Suicide Prevention
If it is an emergency and you feel like you or someone else is at risk, call 111.