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Assessment and risk evaluation of a mental health inpatient; discharge planning and systems to ensure continuity of care (09HDC01156)
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(09HDC01156, 29 April
Psychiatrist ~ District health board ~ Mental health
services ~ Inpatient services ~ Community services ~ Standard of
care ~ Communication ~ Continuity of services ~ Rights 4(1), 4(2),
A man came under the care of a district health board's mental
health services having had symptoms suggesting a major mental
illness for about two years. The man had ongoing contact with the
mental health services, including admission to the inpatient unit.
His care in the community was managed by two teams.
Ten years later, the man was admitted to the inpatient unit. The
community team was concerned about treating the man in the
community on a voluntary basis and felt that the inpatient clinical
team should seize the opportunity of informal admission to assess
the man and re-establish intramuscular injections. As he would not
agree this the community team suggested using the Mental Health
(Compulsory Assessment and Treatment) Act to compel the
He was assessed by a psychiatrist who planned to keep him as an
inpatient for a brief stay until accommodation could be arranged
for him. The psychiatrist recorded that he saw no evidence of
psychosis or disorganisation. At times the man refused to take his
medication, but the clinical team considered the man's condition
was not such that it was appropriate to apply for a compulsory
In the second week of this admission, the man was found smoking
and consuming alcohol in his room, and he was advised that he was
to be discharged the next day. His family was not consulted or
informed of his impending discharge. The man had no fixed address
and stated that he intended to travel out of the city. He was given
a summary of his admission to present to another mental health
unit, if necessary, and a prescription for medication. The man had
no further contact with the mental health team (except for a phone
call, some weeks later, to the crisis team when he reported being
on the street and cold), but there was some contact with his family
who contacted the teams, expressing concern about the man's
condition. The man was subsequently acquitted of a serious criminal
offence on the grounds of insanity.
Breach - Psychiatrist
The psychiatrist was not the man's treating psychiatrist, and
the man's care was provided by a multidisciplinary team. However,
as the leader of the team, the psychiatrist had a supervisory role,
and provided oversight to the rest of the team.
The Commissioner accepted that, during the time the man was in
the unit, it was open to the team to conclude that there was
insufficient basis to institute compulsory treatment under the
Mental Health Act. However, the psychiatrist did not fully explore
and set out the risks and benefits of compulsory treatment.
It was found that a reasonable and competent clinician, when
confronted with the combination of a patient with a history of
violence, medication non-compliance and reluctance to co-operate
with treatment plans, would have done a more thorough assessment
and evaluation of risk. The psychiatrist did not adequately assess
the man or evaluate the risks of his treatment plan at that time by
taking a longitudinal view and identifying that his mental health
was deteriorating. In addition, the psychiatrist did not adequately
record his assessment, and therefore did not provide services with
reasonable care and skill. Overall, the psychiatrist breached
Rights 4(1) and 4(2).
Breach - the DHB
When a patient is to be discharged from the acute inpatient unit
to the community, ideally there should be a discharge planning
meeting with the relevant providers.
The DHB's protocol stated that the unit staff had a
responsibility to maintain contact with the community keyworker and
provide information significant to the consumer's progress, and to
consult with the keyworker around any planning decisions. There had
been some previous discussions with the man's keyworker about his
care, but there is also no evidence in the patient notes that the
unit staff consulted with him or any other community mental health
staff about the decision to discharge.
Decision to discharge
The multi disciplinary team's psychiatric house surgeon, a
medical student and a ward nurse met with the man to discuss his
pending discharge. The house surgeon noted that the man appeared to
be no risk to himself or others, although his safety issues had not
been formally assessed. Staff at the unit had encouraged him to
arrange accommodation for himself, but he indicated that he wanted
to remain in the unit, and made little effort to find somewhere to
live. At the time the discharge decision was made the man had only
a vague notion of where he would live.
The man's family were proactive in following up with the mental
health service staff and expressing their concerns about, and
wishes for, their son's ongoing treatment. However, they were not
consulted about the proposal to discharge him.
The communication between the ward and the community mental
health team was not as good as it should have been. The discharge
plan was based on an assumption that the man would continue to take
his medication, when it was already evident that he was
non-compliant. It was unrealistic to expect that he would keep in
contact with the community teams, when he had exhibited a
reluctance to interact with his key community worker while in the
The DHB's policy, which was intended to provide staff with
guidance on discharging a consumer who is known to the service to
have no accommodation, was not sufficient. The DHB also did not
have appropriate procedures, or take appropriate action to ensure
that the protocol for liaison between the inpatient unit and
community mental health services regarding discharge was being
followed by staff. This contributed to the man being discharged
into the community without adequate liaison and consultation with
his keyworker (or other staff), and without definite accommodation
and appropriate plans in place for action should he make contact
Follow-up after discharge
The follow-up arrangements were that, should the man require
readmission owing to relapse or non-adherence to the treatment
plan, consideration was to be given to restarting his compulsory
treatment. The man was discharged into the care of the community
team that assists homeless people. Patients under care of this team
are always likely to be difficult to follow up. Yet there was no
plan of what to do should an "elusive" patient such as this man
make contact. A clear plan for his future care and the involvement
of community mental health services should have been agreed upon,
and activated, before he was discharged. There was a missed
opportunity when the man made contact stating that he was on the
street and cold, and that he wanted medication, somewhere to sleep
and some warm clothing. He was told these could not be provided.
His family unsuccessfully attempted to raise concerns about the
man's condition. The DHB lacked appropriate systems to ensure
co-operation between its teams to achieve the appropriate quality
and continuity of services for consumers.
For these reasons the DHB did not provide services of an
appropriate standard to the man in relation to his discharge,
continuity of care and the follow-up in the community, and this
amounted to a departure from the accepted standard. Accordingly,
the DHB breached Rights 4(1) and 4(5) of
The DHB conducted external and internal reviews of its adult
mental health services as a result of these events, and took steps
to steps to address the recommendations arising from these reviews.
These actions include: improvements in the processes between
community mental health services and Court liaison; improved
interface between general and forensic mental health services;
implementation of staff training regarding dual diagnosis; and the
establishment of a restructured community service.
It also took steps to improve communication between the mental
health service and families. The DHB restructured the position of
family advisor, undertook an audit of practice, and improved
consultation policies and accountability.
District Health Board
It was recommended that the DHB apologise in writing to the
families involved for its breaches of the Code. The written
apologies were to be sent to the Commissioner for forwarding to the
It was also recommended that the DHB take the following
- Develop clear performance criteria and processes for review of
performance of the unit's Clinical Director and all mental health
service medical staff.
- Develop a clear mechanism to resolve any disagreement between
and within the community and inpatient teams in relation to
proposed treatment or discharge plans, including when clinicians
have markedly different views.
- Develop a system whereby a "red flag" appears in the electronic
record when a patient comes to the attention of one of the mental
health services because of a relapse or non-adherence to treatment,
and whose historical pattern and clinical records indicate a
history or risk of violence.
- Contract an independent reviewer to critically appraise the
appropriateness of the changes made to the DHB's mental health
services as a result of the recommendations arising from the
reviews undertaken, in particular the:
- discharge protocol;
- interface between the adult acute inpatient unit and Agency 1
regarding discharge planning;
- interface between mental health and addiction services;
- inpatient management model;
- observation procedures;
- criteria for triggering a complex case review;
- training for senior medical and nursing staff regarding
diagnosis, assessment and management of clients with comorbid
substance use disorders; and
- adult acute inpatient unit leadership.
5. Provide evidence that internal auditing and monitoring
processes have been introduced to audit compliance with the DHB's
mental health services policies and procedures.
Ministry of Health
The DHB has made service changes to its mental health services.
It was recommended that the Ministry of Health monitor the DHB's
progress with these changes, and the recommendations above, and
provide an update to HDC.
- A copy of the full report will be sent to the Coroner and the
Medical Council of New Zealand.
- A copy of the report with details identifying the parties
removed, except the expert who advised on this case and the DHB,
will be sent to the Royal Australian and New Zealand College of
Psychiatrists, and it will be advised of the psychiatrist's
- A copy of the report with details identifying the parties
removed, except the name of the expert who advised on this case and
the DHB, will be sent to the Ministry of Health, the Mental Health
Commission, the Mental Health Foundation, and the Schizophrenia
Fellowship, and will be placed on the Health and Disability
Commissioner website, www.hdc.org.nz, for
 Right 4(1) of the Code states:
"Every consumer has the right to have services provided with
reasonable care and skill." Right 4(2) states: "Every consumer has
the right to have services provided that comply with legal,
professional, ethical, and other relevant standards."
 Right 4(5) states: "Every consumer
has the right to co-operation among providers to ensure quality and
continuity of services."