Warning: This story discusses suicide and may be distressing.
The circumstances around the death of a mental health inpatient is to undergo further scrutiny.
The Mental Health Commissioner has found a district health board failed to care for the man who died four days after attempting suicide in his room.
Photo: RNZ
Kevin Allan found the DHB in breach of the Code of Health and Disability Services Consumers' Rights for failures in the care of the man at a mental health inpatient unit, and has referred the DHB to the Director of Proceedings.
The man in his sixties had a complex clinical background including a history of mental illness.
After he was admitted for diagnosis, his condition deteriorated.
He was monitored over the weekend, but on the Monday morning - during three hours when he was not checked - he attempted to take his own life, and died four days later.
The commissioner found the DHB failed to transcribe possible diagnoses onto the man's admission form accurately, to fully document a medical plan for care or to document a nursing plan.
The DHB also failed to ensure the man's room was checked for risk points, to complete hourly observations after 6.30am, and to escalate the man's care when his condition deteriorated.
The DHB did not have appropriate policies for observations and escalation of care.
"Given the context, I am concerned that, following admission, a nursing care plan was not developed for the man, and that the documentation of his medical care plan was incomplete.
"In addition, several staff demonstrated a lack of critical thinking about the care that [the man] required overnight, and a lack of initiative in addressing his deteriorating condition."
Allan made a number of recommendations to the DHB, including that it finalise an escalation policy and provide evidence of training on this, audit staff compliance with hourly observation plans, assess and provide training on communication and teamwork skills within the team, conduct a review of risk assessments, and audit the efficacy of new handover and admission forms to ensure relevant information was captured.
He also recommended that the DHB apologise to the man's family for its breach of the code, which the DHB has since done.
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: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
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Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.