Palmerston North Hospital's mental health ward was ruled not fit for purpose. Photo:
The deputy Health and Disability Commissioner has found a consultant psychiatrist and Te Whatu Ora breached the code by placing a mental health patient in seclusion illegally at Palmerston North Hospital five years ago.
The hospital's mental health ward was ruled not fit for purpose after the deaths of two patients in 2014, and a new ward will be built.
In a report released today, Deborah James said the man was detained in seclusion half an hour before the required paperwork was completed, when he arrived at the hospital's emergency department one afternoon in April 2018.
He told the deputy Health and Disability Commissioner that he was held in the seclusion room for 19 hours, and that this was "an extremely traumatic" experience for him.
James said a lack of communication, including no handover between doctors, contributed to the situation, which was frustrating for the man and his family.
Both the psychiatrist and Te Whatu Ora were found to be in breach of the Code of Health & Disability Services Consumers' Rights (the Code) for not following the legal process designed to protect vulnerable mental health patients.
"This case highlights the importance of following the legal process designed to protect vulnerable mental health patients and of effective mental health care within the community, including the effective co-ordination of care," James said.
The errors began in 2017 when a treatment plan was sent to the man's former GP and he did not receive an appointment letter from Te Whatu Ora.
James said this resulted in a lack of support, frustration and confusion concerning conflicting direction over the man's medication, and she found Te Whatu Ora breached the Code which states every consumer has the right to co-operation among providers to ensure quality and continuity of services.
The following year, the man who is in his 30s went to Palmerston North Hospital's emergency department for treatment for his mental health condition.
He waited two hours, during which time he "got very anxious and agitated" and was walked to the nearby community mental health rooms, where he was seen by a doctor and told he would be admitted to the high needs unit due to his being at risk of suicide.
The report describes how the man then said he wanted to go home and was intercepted trying to leave the building, then taken to the high needs unit by car under the escort of two nurses and two security officers.
On arrival at the high needs unit, he was told he was going straight to seclusion and described in the report what this felt like.
"Felt anxious. Didn't understand why I was going through this process. Even in [Community Mental Health] there wasn't really a conversation - was just 'read your file, you are sick, need to be committed'."
The paperwork required under the Mental Health Act was not completed before the man was placed in seclusion, the afternoon he arrived at hospital.
It was completed around half an hour later, and the hospital said he was taken out of seclusion later that evening.
However, the man said he was released from seclusion the following morning, after 19 hours in seclusion.
James said the man should have remained in an interview room until the paperwork had been completed.
The assessing psychiatrist had arranged for the man to be admitted to the High Needs Unit and detained as an inpatient to undergo further assessment and treatment.
But a lack of communication and inadequate handover, including no handover between doctors, resulted in the man being placed in seclusion.
"She did not provide an adequate handover of care, or follow the legal requirements under the Mental Health Act," James said of the consultant psychiatrist.
The deputy commissioner also found Te Whatu Ora was in breach of the Code, which states every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
James has made a number of recommendations, including that Te Whatu Ora and the psychiatrist providing written apologies to the man and his family.
She has also asked the Medical Council to consider whether a review of the psychiatrist's competence is warranted.
Since the complaint, Te Whatu Ora said it had put in place important improvements in its processes to ensure that an incident of this nature does not occur again in the future, which has resulted in a significant reduction in the use of restrictive practices, including seclusion.
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