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Palmerston North Hospital, Manawatū. Photo: Jimmy Ellingham, RNZ
The father of a teenager who died in a suspected suicide at Palmerston North Hospital's mental health ward is disappointed to learn staff had been sending warnings to hospital management about the unit.
Karl Pearce's 19-year-old son Braden died while a patient at the hospital's ward 21 in October 2021.
More than 18 months earlier, an occupational therapist on the ward sent an email to management titled: "Urgent concerns about ward 21".
The therapist told them the ward frequently had too many patients, so staff couldn't spend adequate time with them to accurately assess their mental state.
The clinician called for an investigation and action.
"As a clinician I currently don't believe that ward 21 is a safe environment for patients or staff, and I believe that a suicide or serious adverse event is highly likely."
Hospital management disputed much of what the clinician wrote, but Pearce was saddened by its prescience.
"It is disappointing to hear that the clinician felt strong enough that she sent a concern, and that was just 18 months before my son's death. I can see that she talked about ward 21 not being a safe environment for patients or staff.
"That shows through in the numbers."
Those numbers, obtained by RNZ under the Official Information Act, show an increase in attempted self-harm incidents on the ward - from 34 in 2018, 88 in 2021 and 61 last year.
In Braden's case, details of an attempt at self-harm the day before he died weren't passed on to staff between shifts.
"These attempted self-harm events are quite likely to move into more serious self-harm attempts or suicide attempts, so they should be red flags," Pearce said.
In November 2020, a New Zealand Nurses Organisation delegate - whose name is redacted - wrote to hospital management about problems staff were facing.
"The majority of staff are feeling overwhelmed, burnt out and unsupported," the delegate wrote.
"The senior management appear to be oblivious to the stress and fatigue of their staff."
Braden, in an artwork by Hana Tawhai. Braden died in a suspected suicide in October 2021. Photo: RNZ / Jimmy Ellingham
A month earlier, Palmerston North hospital manager Richard Barrass sent an email to ward staff about its observation policy.
"Failure to maintain the required observations increases the risk to the client.
"Where an increase in risk or harm occurs to a client through staff not maintaining the required observations, it would be seen as an extremely serious failure in clinical care requiring a formal investigation to take place."
But, in late October 2021, Braden - whose last name RNZ has agreed not to use at the request of Pearce - was under observation every 30 minutes, and this did not change after his attempt at self-harm.
And it had been downgraded too quickly from once every 15 minutes when he was admitted, and after another change.
Pearce said problems with patient observation went back years.
"It's right here in the email that we're aware of, in 2020, and of course it happened with my son in 2021. If this is a continued issue with staff policy, or staff just following policy, then we're going to see more deaths on the ward."
'Tired of waiting years for an answer'
The ward was found not fit for purpose after the deaths of two patients in 2014, Erica Hume and Shaun Gray.
A new ward will be built by 2025, but has faced delays and a budget blowout.
Until it opens patients are still admitted to the old ward, and Pearce said he was worried nothing was changing.
"For myself and the other families who are speaking out about this, some of us are tired of waiting years for an answer," he said.
"I'm looking at waiting years as well, because there isn't yet a time being made for Braden's coroner's inquest.
"That's difficult when we're talking about a ward that is still not fit for purpose."
Pearce said he was worried another death was possible.
Te Whatu Ora MidCentral operations executive for mental health and addiction services Scott Ambridge said it had reviewed leadership and staff structures, so workers were supported and their hours monitored.
Te Whatu Ora was continually working to increase staffing.
"We acknowledge that recruitment is a challenge faced across the motu, but know this is important to ensure current staff are supported."
Polices and procedures were regularly reviewed, and since Braden's death a change to the observation policy and practice had been implemented.
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