Philip Lucas was allowed to leave Palmerston North Hospital on Christmas Eve, 2022. His body was found a month later in Kāpiti. Photo: Supplied
Warning: This story mentions suicide
- Family of Palmerston North Hospital mental health ward patient want new review into facility
- Report uncovers shortcomings in his care about communication with family and recording key information
- Report makes eight recommendations; hospital says it is developing a plan in response
- New ward to open next year - a decade after the present one was ruled unfit for purpose
The family of a patient found dead after he failed to return to the mental health ward at Palmerston North Hospital are calling for a review of the facility, as an internal investigation into the incident uncovers shortcomings in the man's care.
Philip Lucas was granted leave from the hospital on 24 December 2022. His body was found a month later in the Kāpiti area and a coroner is looking into his death.
Te Whatu Ora Health NZ completed a serious adverse event review into the 69-year-old's death, which outlined problems with the recording of key information concerning Lucas' stay and a lack of clarity about communication with his family.
Family calling for review of Palmerston North mental health
The report was much changed from the draft, revealing information that was new to the family.
A spokesperson for the family said it did not go far enough, however, and did not demand accountability.
"The family feels after all of these things they've been dragged through the mud for nothing."
The family would like to see a "thematic review" of Ward 21, which in 2015 was found unfit for purpose after the suspected suicides of patients Shaun Gray and Erica Hume the year before. Inquests into their deaths were held in 2022, and reserved decisions yet to be released.
Shaun Gray died in Palmerston North's mental health ward in 2014. Photo: Supplied
There have been further deaths since then.
RNZ asked Health NZ if a fresh review was warranted.
Health NZ MidCentral group director of operations Sarah Fenwick said the safety of patients was a top priority and it took seriously every report of a serious adverse event.
"We regularly review our policies and procedures to ensure we are appropriately managing and responding to these events and to reduce the chances of them occurring in the future."
Minister for Mental Health Matt Doocey was also asked about the family's call for a review.
"I have been assured by Health NZ that the safety of their patients is their top priority, and they take seriously every report of a serious adverse event," he said.
"I understand MidCentral regularly reviews their policies and procedures to ensure they are appropriately managing and responding to these events and to reduce the chances of them occurring in the future."
The then-Labour-led-government signed off on a replacement ward in 2020 and it was supposed to open late in 2022. Construction was delayed amid a cost blow-out and it will now open next year.
Staff and family hold concerns
Lucas was admitted to the ward as a voluntary patient on 10 December 2022.
In the report, the family found out Lucas was taken to the bank when on leave and had spoken about wanting to go to a pub for a drink - something not previously disclosed to them, and something they were concerned about.
Initially assessed as having a moderate risk of self-harm, this had changed to low-risk by 21 December. The report said although he had made some improvements, staff and family were still concerned about his well-being.
Lucas took leave by himself on 23 December, and when he returned told a registered nurse he planned to see his daughter the next day and visit a pub.
The report writers queried the nurse about his plans to drink, but were told Lucas' voluntary patient status meant he was free to do as he wished.
His plan did not appear to be documented or communicated to other staff, the report said.
Nobody checked his plan to visit his daughter, and there was no note on Lucas' clinical record about her comments made at a family meeting stating she preferred to see her father on the ward rather than have him visit her.
Philip Lucas was a voluntary patient in the mental health ward, and a nurse who assessed him for leave was not concerned about him. Photo: Police / Supplied
On 24 December, Lucas was granted leave, saying he would return in the afternoon. He did not.
Staff told report writers Lucas' voluntary patient status was relevant to the assessment of his risk. Such patients were usually seen as more co-operative with their treatment.
The registered nurse who assessed him for leave was not concerned about him, and knew he had been out the previous day.
Patients on leave were normally given a card listing ward contact details, but Lucas said he did not need one as he had the number in his phone. That phone was, however, later found in his belongings on the ward.
The report found this registered nurse had no way of knowing it was unlikely Lucas would be visiting his daughter, and the lack of recording his plans about visiting a pub "limited the insight of the clinical team into the level of risk unescorted leave may pose to Philip's well-being".
The family spokesperson said the report did not ask why important information was not being recorded.
Fenwick said although staff worked hard to record required information, regrettably, there were times when that was missed. "We are currently working on an action plan to address this issue."
The new mental health ward at Palmerston North Hospital is expected to open in mid-2025. Photo: RNZ / Jimmy Ellingham
Communication with family lacking
Lucas' family believed his status should have changed to involuntary patient held under mental health legislation, but this did not happen.
The family did not believe their views were taken seriously and there was no documentation noting their request, which had been made due to worries Lucas would stop taking medication if discharged, and relapse.
Staff interviewed by report writers all said Lucas did not fit the criteria to be held under the act.
The family were also confused about the level of information that should have been passed to them.
The spokesperson said Lucas might have been asked for consent about this, but he could not give informed consent due to his state of mind. The family were not told about Lucas' unescorted leave from the ward.
Before his admission, Lucas made an attempt at suicide, and the family were also unaware of this when planning for his discharge.
The report found shortcomings with the hospital's communication to Lucas' family, and there was little reflection in his clinical record that staff sought to clarify this with Lucas.
On the evening of 24 December Lucas was reported as a missing person.
According to the report, security footage and a search of hospital grounds happened on 29 December.
In 2017, Simon Oakley, a voluntary patient at the ward, died by suicide after taking leave. Despite being just metres from the ward's entrance, his body was not found for six days.
After Oakley's death, the then-MidCentral District Health Board head of security said from then on security workers would immediately obtain more information about missing patients and call in extra staff if patients had not returned within 72 hours of taking leave.
Asked about Lucas' case, Fenwick said: "We are constantly reviewing our search procedures policies to make sure we are appropriately managing and responding to these events."
It was not clear, however, when Lucas' phone was found, with his belongings on the ward.
The family spokesperson said this could have affected the area in which the search for Lucas focused, as the phone would have been pinging its location as being on or near the hospital.
The report found that required assessment, observations and care plans were carried out, but there were areas of "system weakness". It said no one factor caused Lucas' death.
"It is likely that because Philip was a co-operative and polite patient amidst a group of inpatients, many of whom would have been admitted under a compulsory treatment order and with resistant and challenging behaviour of one sort or another, policies and procedures for informal patients were not rigourously applied."
The report makes eight recommendations about improving communication with families, better recording of information to the clinical record, and strengthening leave procedures.
Fenwick said Health NZ was developing an action plan to address each recommendation.
She also apologised for the lateness of the report, which was supposed to be completed within 70 days of when a provider - in this case Health NZ - was notified of a serious event.
The final report into Lucas' death was given to his family in the middle of this year.
Where to get help:
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
- Lifeline: 0800 543 354 or text HELP to 4357
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
- Depression Helpline: 0800 111 757 (24/7) or text 4202
- Samaritans: 0800 726 666 (24/7)
- Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
- What's Up: free counselling for 5 to 19 years old, online chat 11am-10.30pm 7days/week or free phone 0800 WHATSUP / 0800 9428 787 11am-11pm
- Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi and English.
- Rural Support Trust Helpline: 0800 787 254
- Healthline: 0800 611 116
- Rainbow Youth: (09) 376 4155
- OUTLine: 0800 688 5463 (6pm-9pm)
If it is an emergency and you feel like you or someone else is at risk, call 111.