Photo: RNZ / Marika Khabazi
A scathing report has found Te Whatu Ora Counties Manukau responsible for the death of a mental health patient in his 30s after a suspected suicide.
The Deputy Health and Disability Commissioner (HDC) found the man was given inadequate care whilst being transferred to another Te Whatu Ora district he recently moved to.
After he was discharged from Middlemore Hospital in 2018, his transfer was seen as insufficient because there was a delay in contacting him.
This was a critical moment missed after Te Whatu Ora Counties Manukau did not follow up with him after an inpatient admission.
Deputy Health and Disability Commissioner, Dr Vanessa Caldwell said Te Whatu Ora Counties Manukau was in breach of right 4(1) of the Code of Health and Disability Services Consumers' Rights for not providing services with reasonable care and skill.
Right 4(5) was also breached for the lack of cooperation between providers to ensure quality and continuity of services.
"I consider that the onus was on Te Whatu Ora Counties Manukau as the transferring service to initiate and complete the transfer of the man's care appropriately and within accepted guidelines," Caldwell said.
"The National Transfer of Care Guidelines are clear and concise and in this instance transfer of care did not adhere to the guidelines. I am critical that, particularly in the context of mental healthcare, more was not done by Te Whatu Ora Counties Manukau to transfer the man's care safely.
"Overall, this led to a poor standard of care at the point of discharge."
The report found communication with the man's support person was also poor, leaving him alone without anyone organised to pick him up or drop him off.
There was no aftercare plan issued to the man or his whanau, which would have included important emergency contacts such as the follow-up mental health team.
Cladwell's recommendations included Te Whatu Ora Counties Manukau apologising to the man's whanau for the code breaches. They also included providing HDC with an update on changes made after this event and any future changes.
The HDC said it should consider developing a guideline about transport and supervision when a patient transfers from different areas within the organisation.
It also recommended a review on work pressures in-patient unit staff are faced with.
Caldwell noted that since this incident in 2018, Te Whatu Ora Counties Manukau had improved its assessment and management of risk with a safety assessment.
It had increased whanau involvement in safety planning and reviewing discharge procedures.
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