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Provision of co-ordinated services to mental health patient (07HDC16607)
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(07HDC16607, 8 January 2009)
District health board ~ Psychiatrist ~ Mental health ~
Factitious disorder ~ Police manslaughter investigation ~ Rights
The family of a mental health patient complained about the
services provided by a district health board. The patient was well
known to the mental health service and had been reviewed over a
number of years for ongoing treatment of schizoaffective disorder.
However, due to the patient's atypical presentation, there was a
view that he might have factitious disorder.
Following a period where the patient remained stable, he was
discharged to the care of his GP. The patient subsequently
deteriorated but, despite repeated contacts by family, friends, his
GP and other services, he was not accepted back into the mental
The patient was eventually assessed and readmitted to the mental
health service. However, while in the high security unit (and left
unobserved for 15-35 minutes), he was found unconscious. He died
It was held that the DHB did not respond adequately to repeated
contacts for assistance. In failing to record a clear care plan, an
unco-ordinated and unassertive approach to care resulted, which
contributed to delay in treating the man's deterioration.
Accordingly, the DHB breached Right 4(5).
Staff should have explored involving the family, particularly in
relation to the provision of ongoing support and crisis management.
The failure of DHB staff to do so suggests that the DHB's policy
was not well known to staff. By failing to ensure that staff
adequately considered involving the man's family in his care, the
DHB did not comply with relevant standards and breached Right
On the day the patient died, staff failed to communicate the
increased risk of self-harm at the time of the man's transfer to
the high security unit, in breach of Right 4(5).
A Police manslaughter investigation lasting three and a half
years delayed the HDC investigation and the normal accountability
processes in this case.