Warning: This story contains reference to self-harm
The family of a man who died after falling two storeys out of a Palmerston North Hospital window say urgent changes are needed to avoid a repeat.
They want to see new mental health and security procedures introduced.
Palmerston North Hospital. Photo:
The hospital has confirmed it has strengthened a mental health consultation team, but Paul Rowe's family said that doesn't go far enough. They have previously said the hospital was negligent in its care of Rowe, and they hold it responsible for his death.
The 58 year old jumped or fell out of a window next to his hospital bed and lay fatally injured for two-and-a-half hours before he was found in June.
His death is under investigation by a coroner, and RNZ has received permission to publish the circumstances of his death.
Rowe was admitted to Palmerston North Hospital two days earlier with a serious, self-inflicted wound, but was not assessed by a mental health team.
He went missing from a general ward, where he was under periodic observation after recovering from surgery to repair his wound.
Searchers initially failed to check the balcony below the window, where he lay injured. Nor did they initially check CCTV footage of the ward to see how he left.
Paul Rowe, 58, died at Wellington Hospital after suffering injuries at Palmerston North Hospital. Photo: Supplied
Rowe's sister Lisa Stevenson said there should be protocols for when a patient goes missing.
"I think procedures with security should be strengthened and fail-safe to ensure that every possible area is searched and no assumptions are made.
"That's very important and that needs to be documented and rolled out as a matter of urgency."
Stevenson said it was assumed her brother couldn't have escaped out the window near his bed, which he did climb or jump from, and that he couldn't access the balcony where he was eventually found because it was closed after hours.
At one point, security staff thought they'd identified Rowe outside smoking, but didn't escort him back to the ward nor check identification, which would have revealed it wasn't Rowe.
A draft MidCentral District Health Board serious adverse event review report into Rowe's death identified several "opportunities for improvement".
These included security reviewing its procedures and a better process to give security and police information.
RNZ asked the board for an interview about what changes had been implemented.
A written statement from the board's acute and elective specialist services operations executive Lyn Horgan said it was in regular contact with Rowe's family before the report and its recommendations were finalised.
"The DHB has recently strengthened the mental health consult liaison role by increasing resources, which includes moving to a seven-day roster to improve communication and responsiveness."
Horgan said the board couldn't discuss detail's of Rowe's death until the coronial findings were published.
For Lisa Stevenson, the changes to the mental health team aren't enough.
"There are so many areas that there need to be changes made, but specifically, it's to do with security, with searchers and also with mental health," she said.
"There should actually be a 24-7, seven-day roster. I'm unclear as to whether that has actually happened."
Patients with possible mental health needs should be assessed within a few hours of arriving at hospital, Stevenson said.
Her brother's assessment was repeatedly delayed.
"It was just put off day after day and, 'We'll see him tomorrow', and that obviously never happened.
"It was too late to give him a proper assessment, and his observation or care was downgraded to 15-minute obs [observations], which is a big factor in what happened to our brother, father and poppy Paul."
Rowe's death is one of at least six of mental health patients at the hospital since 2014, when two died in suspected suicides on the mental health ward.
A new unit is due to be built this year after reviews found the existing one not fit for purpose.
Figures released to National Party mental health spokesman Matt Doocey show how much pressure it is under.
"When you look specifically at MidCentral DHB, their occupancy rates at their mental health inpatient facility have increased from 88 percent in May 2020 to a staggering 103 percent in September 2021."
Nationwide, occupancy rates rose from 80 percent to 90 percent during that time.
Doocey said the average occupancy in June for Palmerston North, the month of Paul Rowe's admission, was 108 percent.
"Occupancy rates in the MidCentral DHB inpatient facility have at times been as high as 110 percent, so that's hugely concerning for any family or friend of someone who's in an inpatient facility, not only in MidCentral but across the country."
Horgan said Palmerston North Hospital's new ward would have 28 beds.
"The design of the [ward] has been developed to include an additional eight beds should they be required in the future."
Preliminary design work was done and the "secondary design phase" under way.
She said there was no link between mental health ward occupancy and the functions of the mental health liaison service, which supported patients elsewhere.
Stevenson said it was important appropriate procedures were in place as well as a new facility.
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