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Names have been removed (except BOPDHB and the expert who
advised on this case) to protect privacy. Identifying letters are
assigned in alphabetical order and bear no relationship to the
person's actual name
Bay of Plenty District Health Board
Psychiatrist, Dr C
A Report by the Health and Disability Commissioner
Table of contents
Information gathered during
Response to provisional
Opinion: Breach - Dr C
Opinion: Adverse comment - Mr
Opinion: Breach - Bay of Plenty District
Appendix A - Independent expert psychiatric
advice to the Commissioner
- This opinion concerns the care provided by mental health
services to Mr A, who since 2006 had been variously diagnosed with
bipolar affective disorder, personality disorder with mixed
features, and cyclothymic disorder. This opinion concerns Mr A's
care over a period of four months (Months 1-4) until his death by
suicide, in 2010.
- On 23 Month1 2010, Mr A's partner, Ms B, approached the
psychiatric acute community team (PACT) reporting Mr A's
non-compliance with medication and his abusive behaviour, which had
caused her to move out of the house. PACT discussed with Ms B the
possibility of compulsory treatment under the Mental Health
(Compulsory Treatment and Assessment) Act 1992 (MHA) and advised
her to see Mr A's GP, Dr G, but did not inform Dr G of this
- On 22 Month2 2010, Mr A attempted suicide, resulting in his
admission to hospital. He was reluctant to engage in an assessment
by PACT, and was discharged from the Emergency Department to a
respite facility as he was homeless. He had brief daily checks by
PACT but no further attempt was made to conduct a full mental state
- On 26 Month2 2010, Mr A attended an outpatient assessment with
psychiatrist Dr I, who made a diagnosis of lifelong personality
disorder with acute decompensation in coping and risk in the
context of social stress. During the assessment Mr A self-harmed
which he later told staff was because Dr I had not diagnosed him
with bipolar affective disorder. Mr A was admitted to the intensive
- Mr A was discharged home from the intensive care unit on 28
Month2 2010, following an assessment by the consultation-liaison
team psychologist who found no acute mental illness and no acute
risk as "the relationship issues with his partner [appeared] to
have now resolved". There had been no communication with Ms B about
Mr A's discharge and no follow-up with mental health services was
- After two referrals from Dr G, Mr A was accepted for
psychiatric outpatient reassessment by Dr C. The assessment on 4
Month4 2010 was also attended by registered psychiatric nurse Mr D.
Dr C was unable to complete the assessment in one session and a
further appointment was planned for one month's time, when Dr C
returned from leave.
- Dr C made an interim crisis plan in which Mr D was to be Mr A's
point of contact for any concerns or crises during working hours.
Only Dr C, Mr D and Mr A were aware of Mr D's role. The PACT was
unaware that Mr A had been assessed by Dr C, or of Mr D's role in
Mr A's care.
- Dr C's handwritten notes were placed on Mr A's hard file but
these did not document the crisis plan or the role of Mr D, and
neither Dr G nor Ms B was informed of the assessment outcome.
- Ms B approached the PACT three times between 15 and 17 Month4
2010 with concerns about Mr A's behaviour and threats of suicide.
Apart from advising her to take steps to remove Mr A from her home,
the PACT did not respond to these concerns. Although Mr A's
electronic record showed that he had attended an outpatient
appointment with Dr C two weeks earlier, the PACT overlooked this
and did not access his paper file.
- The mental health services were aware that the
relationship breakdown and imminent eviction of Mr A were
significant risk factors for his self-harm, however no arrangement
was made to review Mr A.
11. Mr A was found dead from suicide a few days later.
12. When Dr C returned from leave, he dictated a reporting
letter to Dr G about the 4 Month4 2010 assessment, which Dr G
received on 6 Month5 2010.
13. It is important to note that that my role does not extend to
determining cause of death. I am primarily concerned with the
quality of care provided to the consumer and whether that care
accorded with the requirements of the Code of Health and Disability
Services Consumers' Rights (the Code). The breach findings of the
Code do not imply any individual was responsible for Mr A's
14. Dr C failed to maintain adequate records and so breached
Right 4(2) of the Code. Dr C's failure to
communicate with Dr G or take appropriate steps to communicate with
Ms B, together with the failure to take adequate steps to ensure
that the crisis plan was documented on Mr A's clinical record,
meant that Mr A's continuity of care was compromised. Dr C thereby
breached Right 4(5) of the Code.
15. Mr D failed to ensure that his role as Mr A's point of
contact within the mental health service was documented on Mr A's
clinical record and failed to contact Mr A following the 4 Month4
2010 assessment. However, no breach was found due to the District
Health Board's lack of clarity around Mr D's role as the second
16. Bay of Plenty District Health Board (BoPDHB) missed
opportunities to assess Mr A on at least two occasions in
mid-Month4 2010 when Ms B presented to the PACT with concerns about
Mr A's mood, suicide threats, and impending eviction. Mental health
staff failed to contact Mr A for assessment once his known risk
factors occurred. Accordingly, BoPDHB breached Right 4(1) of the
17. BoPDHB failed to take appropriate steps to discuss the
discharge plan with Ms B and so did not comply with the National
Mental Health Sector Standards and the organisational standards of
discharge planning. Accordingly, BoPDHB breached Right 4(2) of the
18. The failures in co-ordination between the Community Mental
Health team (CMH), the PACT and Dr G impaired Mr A's continuity of
care. Accordingly, BoPDHB breached Right 4(5) of the Code.
Complaint and investigation
19. On 12 July 2010, the Health and Disability Commissioner
(HDC) received a complaint from Ms B about the services provided by
mental health services to her late partner, Mr A. The following
issues were identified for investigation:
- The appropriateness of psychiatric care provided to Mr A by
the Bay of Plenty District Health Board in 2010.
- The appropriateness of psychiatric care provided to Mr A by
Dr C in 2010.
- The appropriateness of care provided to Mr A by Mr D in
20. An investigation was commenced on 14 June 2011.
21. Information was reviewed from:
Bay of Plenty District Health Board - provider organisation
Ms B - complainant
Dr C - psychiatrist, BoPDHB CMH
Mr D - psychiatric nurse & case manager, BoPDHB, CMH
Mr E - psychiatric nurse, BoPDHB PACT
Mr F - psychiatric nurse, BoPDHB PACT
Dr G - general practitioner
Also mentioned in this report:
Dr H - psychiatrist
Dr I - psychiatrist
Mr J - clinical psychologist
Dr K - psychiatric registrar
Ms L - C-L psychologist
Ms M - CMH intake co-ordinator
22. Independent expert advice was obtained from psychiatrist Dr
Murray Patton and is set out in Appendix A.
gathered during investigation
23. In 2006, Mr A, then aged 45 years, was tentatively diagnosed
with bipolar affective disorder by his GP, Dr G. He was commenced
on lithium, paroxetine and buspirone and there was an
apparent improvement in Mr A's mood.
24. In 2007, Mr A first became known to Bay of Plenty District
Health Board (BoPDHB) Community Mental Health team (CMH), when Dr G
referred him for "diagnostic clarification and treatment
25. From August 2007 to February 2009, Mr A was a patient of the
CMH service. During this time he received
separate psychiatric assessments from two consultant psychiatrists,
Drs I and H, and 14 months of anxiety management and cognitive
therapy from clinical psychologist, Mr J. The diagnostic conclusion
by all three practitioners was that Mr A did not suffer from a
major mood disorder. Rather, Dr I and Mr J felt Mr A had a
significant personality disorder with mixed features including
paranoid, narcissistic and avoidant traits, while Dr H suggested a
diagnosis of cyclothymic disorder or mood
disorder NOS (not otherwise specified), noting that Mr A's
motivation for a diagnosis of bipolar affective disorder was to put
his eligibility for a WINZ benefit on a "sound footing". Mr A was
discharged from CMH when he no longer wished to engage with the
service, case management or have further contact with a
26. In early 2009, Mr A met Ms B. At the time, he was living in
a caravan park. Later he moved into Ms B's house with her. During their time
together, Ms B was of the opinion that Mr A was suffering from
bipolar affective disorder and high functioning Asperger Syndrome.
He had been estranged from all family members for several years and
had no other significant relationships.
27. This opinion considers Mr A's treatment from Month1 2010
until his death by suicide in Month4 2010.
Month1 2010 - contact with the PACT
28. On 23 Month1 2010, Ms B approached the CMH crisis team
(PACT), concerned at the behaviour of Mr A,
who was identified as her flatmate. She expressed concern that Mr A
was unwell, agitated and abusive and had not been taking his
medications for bipolar affective disorder. She described how Mr A
would not talk to her, he had been isolating and controlling and
she had moved out as she no longer felt welcome in her own
29. The note of this meeting records a discussion about the
possibility of implementing the Mental Health (Compulsory
Assessment and Treatment) Act 1992 (MHA) process for compulsory
treatment. Ms B was advised to see Mr A's GP. No further contact
with the mental health service was planned. CMH did not communicate
with Mr A's GP about this contact.
Suicide attempts - Month2 2010
30. On 22 Month2 2010, Mr A was seen by CMH in the Emergency
Department (ED). He had attempted suicide. Ms B stated that Mr A
had stopped his medication months previously and his mood and
behaviour had deteriorated.
31. Mr A was assessed by on-call PACT staff. The clinical notes
record that the suicide attempt was precipitated by a "relationship
break up" with "his partner [Ms B]", and "[he] has now been made
homeless". There was no record of a mental state examination by the
PACT at this ED consultation. The notes document Mr A's resistance
and reluctance to engage in the assessment and that he expressed
his unhappiness with treatment received from mental health services
in the past, saying he "got the run around at CMH", had trouble
getting on the sickness benefit, and was upset about his diagnosis.
He said he hoped that one day he would get a referral from a
psychiatrist at CMH to a private psychiatrist through ACC. The
documented plan was for the PACT to reassess Mr A's mental state
the following day.
32. Ms B declined Mr A's request to return to her home, but told
nursing staff that she was very happy for the PACT to contact her.
Mr A was discharged from ED to respite accommodation because he was
homeless and at risk of further self harm.
33. Ms B told HDC that her decision that she could not live with
Mr A was because he was not well or safe to be around. She stated
that from her perspective "there were no relationship issues as
such ... The issue was one of his illness not the
34. On 23 Month2, Mr A was discussed at the multidisciplinary
team (MDT) meeting, and a plan was made
for Mr A to have an outpatient assessment with psychiatrist Dr I,
as a condition of Mr A being provided with respite care. The PACT
was to provide daily follow-up while Mr A was in respite care.
35. Mr A's dislike of Dr I was known to Ms B, and she told HDC
that Mr A had previously made a complaint about Dr I. However,
despite expressing anger and indirect threats toward Dr I, Mr A
accepted the outpatient assessment appointment and his respite stay
was extended. Staff at the respite facility reported seeing no
evidence of Mr A suffering an acute mental illness. PACT staff made
phone contact with Mr A's GP to discuss his prescribed medication.
A PACT review on 23 Month2 2010 records that Mr A was not at risk
of suicide and describes him as "very sarcastic and projecting
aspersions upon [mental health] services and its lack of ability to
address or deal with any of his issues". It also notes that Mr A
attributed the cause of most of his problems to CMH.
36. On 26 Month2, a phone conversation was recorded in the PACT
notes, stating that Mr A's "ex landlord / ex-partner" had locked
his belongings in her garage and was wondering who would be
collecting these. It was also recorded that Ms B stated that she
was worried about where Mr A would live and asked if CMH was
37. A further phone call, occurring one hour later, was also
documented by the PACT, in which Ms B reported that Mr A had just
been to her house and left stating that he was going to kill
himself immediately. The PACT advised Ms B to call the police.
38. However, in her response to my provisional opinion, Ms B was
adamant that she never made any telephone calls to the PACT. She
stated that her only phone call was to the respite facility, to
inform staff that she had some clothes and toiletries ready for Mr
A's use to be collected from her house.
39. Later that day, Mr A attended the assessment with Dr I,
during which Mr A attempted suicide. He was transferred to ED and
the Intensive Care Unit (ICU).
40. Dr I identified that Mr A's main problems were anger and
hostility associated with a "lifelong personality disorder with
acute decompensation in coping and risk in the context of social
stress". Dr I considered the possibility of a mood or anxiety
disorder, but thought neither was acutely present.
41. Dr I felt Mr A's suicide risk was unacceptably high in light
of his apparent inability to co-operate with psychiatric treatment
and so Dr I initiated the MHA process to compulsorily treat Mr
42. On admission to ICU, Mr A's psychiatric care was transferred
from CMH to the Consultation Liaison Psychiatry (C-L) service. On 27 Month2 2010,
Dr K, C-L psychiatric registrar, conducted a psychiatric
examination of Mr A under section 9 of the MHA. This assessment was
undertaken in consultation with the on-call consultant
psychiatrist. Dr K concluded that Mr A was not mentally disordered
and was consenting to medical treatment, so the MHA process was
43. Dr K documented Mr A's recent relationship break-up with his
attendant inability to cope and noted that, although Mr A had no
current intent to commit suicide, he said he would if his needs
were unmet. Dr K recalls that Mr A:
"… indicated that he wanted input from mental health
services particularly because he wanted to receive a diagnosis of
bipolar affective disorder (BPAD) which was disputed. At the time
of assessment it was clear that he was especially angry at services
for not giving him this diagnosis and stated clearly to me that he
had made a threat to kill himself … during [Dr I's] meeting because
he did not get diagnosed with BPAD."
44. Dr K's plan was for the C-L service to review Mr A the
following day and for there to be "CMH follow-up".
45. The DHB stated that CMH follow-up "was a logical assumption
of the required follow-up but [Dr K] had not yet had a discussion
with [Mr A] about his very hostile feelings toward the personnel at
46. The clinical notes from 27 Month2 2010, record Mr A telling
a C-L nurse he was grateful for the care from ICU staff, saying
"Don't worry I won't cause any trouble. My beef's not with them but
those over there" (referring to CMH).
47. Ms B visited Mr A during his ICU admission. She said that
she was "distraught that he nearly died". The ICU afternoon shift
nursing note on 27 Month2 2010, records that Mr A was visited by
48. On 28 Month2 2010, Mr A was reviewed in ICU by C-L
psychologist, Ms L, and a C-L nurse. Ms L concluded that Mr A had
no acute mental illness or acute risk and she noted that Mr A's
suicide attempts "occurred in the context of relationship issues
with his partner, which appears to have now resolved …" It was
decided that Mr A would be discharged from BoPDHB's mental health
49. Ms B cannot recall anyone from the hospital contacting her
to discuss Mr A's discharge arrangements, his accommodation, or
their relationship status. BoPDHB has confirmed to HDC that it can
find no reference to a documented discussion between hospital
inpatient staff and Ms B regarding Mr A's discharge
50. There is no record of any attempt to obtain Mr A's consent
to discuss his situation with Ms B or any contact with Ms B to
ascertain her views about the relationship and whether the "issues"
had in fact been resolved. The DHB sentinel investigation report
states, "It would have been insensitive for staff to question [Mr
A's] statements that the relationship had resolved and that he was
returning to his address."
51. Ms L said that she discussed Mr A's case with consultant, Dr
I. Ms L advised that the discharge plan did not provide any CMH or
outpatient follow-up because of Mr A's candid dislike of Dr I, his
disagreements with CMH over diagnosis, and his reluctance to engage
with CMH. She said that the role and availability of the PACT was
reiterated to Mr A.
52. There is an apparent discrepancy between this plan and the
medical discharge letter sent from ICU to GP, Dr G, which stated
"continue psych outpatients". However, in her discharge letter to
Dr G, Ms L made it clear that no CMH follow-up was intended and she
suggested treatment options of primary care funded (CPO)
counselling, Community Relationship Services and the Living Without
Violence programme. Ms L's letter gave a likely diagnosis of
antisocial and narcissistic personality disorder.
53. Ms B said that Mr A walked out of ICU and straight to her
door "with a big grin on his face". She had already had the locks
changed but did not feel she could turn Mr A away as he had nowhere
else to go, so Ms B agreed Mr A could stay, on the condition he
took his medication. She organised for his pills to be dispensed in
blister packs in an attempt to keep track of his compliance.
However, within weeks, he stopped taking them again and became
Re-referral to CMH by GP
54. On 5 Month3 2010, Dr G referred Mr A back to CMH because Mr
A had been declined for CPO counselling because he was felt to be
at too high a risk of self harm for the primary mental health care
programme. The CPO Co-ordinator and CMH Clinical Co-ordinator
discussed the inappropriateness of the referral, given Mr A's high
score of 39 on the Kessler Questionnaire. Apart from the high
Kessler score, there was no indication in Dr G's referral of any
change in Mr A's presentation or circumstances.
55. Dr G's referral was triaged as "non-acute" by CMH intake
co-ordinator, Ms M, and the referral was
discussed at the MDT meeting on 11 Month3 2010. On 11 Month3, Ms M
wrote to Dr G declining the referral for CMH follow-up, stating: "…
based on the information provided, [the referral] did not meet the
criteria for acceptance to our service" and reiterating the
appropriateness of community relationship counselling options. The
CMH team did not contact Dr G for further information.
56. Psychiatrist, Dr C, was present at the MDT meeting and
recalls the referral was declined because it contained "no useful
clinical information". Dr C said that Mr A had been comprehensively
reviewed recently by Dr I, Dr K and Ms L, and the assessments had
consistently failed to find any evidence of a major mood disorder
or psychotic illness. Dr C said that Mr A's reluctance to engage
with treatment was also taken into consideration and he stated:
"The acute crisis had resolved and there were no new concerns".
57. The DHB's investigation report notes that the team who
declined the initial referral was a different team from that which
had previously assessed and managed Mr A's care. The DHB concluded
that this team would therefore not have been aware of Mr A's
previous history of high-risk behaviours at the end of other
relationships. However, it stated that the paper records and
electronic health records are accessible by the staff.
58. On 14 Month3 2010, Dr G again referred Mr A to CMH,
expressing astonishment that Mr A did not fit the acceptance
criteria for the service, and noting the CPO Mental Health Service
had formally declined to see Mr A. Dr G described Mr A's decline in
mental state over the past five years, from previously being high
functioning, to becoming increasingly agoraphobic.
59. This second referral was triaged as non-urgent by Ms M, and
discussed at the MDT meeting on 20 Month3. Dr C, who again was
present at the meeting, said that Dr G's second referral "also did
not contain any psychiatric symptoms, risk or mental state findings
on which we could make an informed decision" and that the tone was
"threatening and unhelpful".
60. Dr C discussed the case with Drs I and K. He said that he
remained unclear "who actually wanted the assessment and for what
particular reason" and that "the pressure to assess Mr A was not on
the basis of clinical information or need but rather the bullying
remarks by the GP and how best to manage this situation".
61. The DHB record of that meeting indicates "[Dr C] will
contact GP", however, there is no documentation in the clinical
notes of any contact having occurred. Because the MDT could not
reach a consensus on the best pathway forward, Dr C decided to
complete a full file review and present the case to the Senior
Medical Officers (SMO) Peer Review for clinical guidance on 28
62. Dr G advised HDC that he was attempting to re-refer Mr A to
CMH because "the PHO rightly declined his counselling assessment."
Dr G commented that some criticism of the content of the referral
letters may have been valid if these letters had been his sole
communication with CMH, "however in the context of a compendious
written dialogue spanning 4 years, and the PHO referral
accompanying, any reasonable person would recognise my increasing
concern for [Mr A's] welfare."
63. The SMO group suggested completing another assessment
because of the complex personality issues involved, and to support
the GP. Dr C recorded this decision by hand on the triage referral
and there is a handwritten note by a CMH secretary that an
appointment was made for Mr A to see Dr C on 4 Month4, prior to Dr
C going on three weeks' leave. The upcoming appointment was entered
into Mr A's BoPDHB electronic (Webpas) file on his "Patient Visit
List" screen. Dr C told HDC that there was no clear clinical
indication to see Mr A urgently, and if he had not seen Mr A in
early Month4, Mr A would have had to wait one to three months,
which is the common waiting time for non-urgent GP referrals.
64. At BoPDHB CMH, the case manager for a service user is the
primary person for contact in treatment planning and co-ordination
of care for that person. Responsibilities include ensuring smooth
transitions along the care pathway for service users and their
families, resolution of distress and effective management of mental
health issues, and re-integration with family and primary care
65. Case managers are usually appointed as a result of a staff
member volunteering for the role, or else the role is assigned by
the Team Leader (consultant) at the clinical MDT meetings. If a
patient is known to the service, the case manager may be allocated
at the time of referral.
66. The consultant can request that the case manager attend the
initial assessment, but that person may not necessarily continue as
the patient's case manager (eg. where a RN attends the appointment,
but it would be more beneficial for an occupational therapist or
social worker to case manage). The case would be discussed at the
clinical meeting and a new case manager allocated.
67. If an initial psychiatric assessment is needed because of
the patient's complexity or the need for diagnostic clarity, then
the case manager might not be allocated until after the assessment
at which the diagnosis and treatment plan are formulated.
68. At the MDT meeting prior to Mr A's assessment, psychiatric
registered nurse Mr D agreed to attend the interview with Dr C.
There is conflict about the capacity in which Mr D attended. Dr C
said that Mr D was "clearly identified as the case manager" at the
MDT meeting. Dr C also stated in response to my provisional
opinion: "I arranged a case manager five days before I saw [Mr A]".
The DHB investigation report refers to Mr D's role as the "case
manager pending the completion of [Dr C's] report". However, Mr D
told HDC that at no point was he requested to be engaged in case
management, as Mr A had not yet been accepted by CMH.
69. Mr D said that if the assessment determined that Mr A was an
appropriate CMH patient, then either he or another colleague would
be appointed case manager. Mr D said he understood that he was
present at the interview "to discuss with [Dr C] [his] thoughts of
[Mr A's] assessment and to communicate this within our MDT
discussion". Mr D stated, "I was asked to attend an assessment. [Mr
A] was not allocated to me at the time of the referral and I could
not have accepted a case management role until after the assessment
and discussion at MDT." The DHB stated that case manager
appointment usually occurs through the clinical meetings, but
added: "Allocation is sometimes done at the time of referral if the
person is known to the service and has been previously care managed
by the team."
70. There was no linked referral made on Mr A's electronic
(Webpas) file, to indicate that a case manager had been assigned to
him (the usual way of circulating this information to internal
providers such as the PACT) and no communication, by phone or in
writing, of case management to external providers (such as the GP).
BoPDHB has confirmed it is the responsibility of the person
appointed as Case Manager to circulate this information.
71. HDC requested that BoPDHB supply the minutes
of the meeting at which the case manager was allegedly appointed.
BoPDHB advised that the relevant team was the "[X] team". All
sector teams meet each morning. The discussions at the meetings are
recorded in a book and then transcribed to the sector team minutes
and relevant entries are made in patients' clinical records. HDC
obtained the relevant sector team meeting minutes, which do not
refer to the appointment of a case manager for Mr A and his
clinical records do not refer to the appointment of a case
72. BoPDHB advised that each team has a separate weekly meeting
which they also record in a book; however, the X team's book for
the period in question is missing.
73. In his response to the provisional opinion, Dr C provided a
copy of his personal diary from 31 Month3 to 6 Month4 2010. On 31
Month3 he has handwritten: "9.00 MDT→ [Mr A] - update - need CM".
Below this is written "[Mr D] [sic] ü". Dr C stated that this entry
"proves [Mr D] did agree to be a case manager."
74. On 4 Month4 2010, Mr A attended the assessment with Dr C. Dr
C advised HDC that he took care to engage Mr A in a therapeutic
alliance. Dr C said he felt the interview process was positive and
that Mr A felt heard and respected. However, Dr C said that as a
result of Mr A "dominating the discussion" the assessment could not
be completed in the allocated 90 minutes.
75. Dr C said his impression was that Mr A suffered from acute
adjustment disorder which was improving.
This had been triggered by Mr A's recent separation and
accommodation issues, which had now been resolved. Dr C said he
found no evidence of major depression, bipolar affective disorder
or Asperger syndrome, and no impairment of insight or judgement. Dr
C said he considered Mr A's risk of harm and reached a view that
there was no immediate concern, given that he had identified no
recent new stressors or dynamic (modifiable) suicidal risk factors.
Dr C noted Mr A "had a low risk of deliberate self-harm but a
chronic risk of aggression and violence toward others."
76. A further appointment was scheduled for a month's time, on 5
Month5 2010, when Dr C returned from leave. This appointment was
for the purposes of completing the assessment and discussing
management options, which were likely to include a psychotherapy
referral. No interim contact was planned. Mr D stated that "The
second health professional/observer would provide ongoing follow-up
if a need had been highlighted in the assessment and a plan had
been agreed with the doctor and patient ... I did not feel I needed
to foster a further therapeutic alliance when there had not been a
decision about offering care and no indication in the assessment of
need to engage further."
77. Dr C said he discussed a crisis plan for the interim period
with Mr A. Mr D agreed to be "a point of contact" within the CMH
service, should Mr A need it for any concerns or crises that arose
during normal working hours. After hours, Mr A was to contact the
78. Dr C stated that there was no clear clinical case management
role he could identify for Mr D because there were no medications,
acute suicidal risk, mental state concerns or psychosocial
stressors that needed monitoring, but he encouraged Mr A to make
contact with CMH service if he had any concerns.
79. Dr C said he believed that the crisis plan was realistic,
given that Mr A had engaged with the PACT a few weeks earlier and
had attended psychiatric assessments voluntarily, even if there was
some "acting out" behaviour. Dr C said that "[Mr A] did want help
to get on with others, unfortunately his own personality and
intolerance of others inevitably got in the way." Dr C stated that
he was mindful of Mr A's dislike of individuals within CMH who he
perceived as rejecting and invalidating, but he believed positive
steps towards engagement had been achieved during the interview and
that Mr A felt respected and validated by him. He stated, "My
clinical judgment at the time of assessing [Mr A] is that he would
make contact with services if he needed support. He did attend
regular therapy sessions with [Mr J], psychologist,
80. Dr C's handwritten notes were placed in Mr A's clinical hard
file, which was held in the central file room and was accessible to
all mental health staff. However, no entry was made on Mr A's
electronic file until 29 Month4 2010, after Dr C returned from
leave and was notified of Mr A's death, at which time Dr C dictated
a ten-page reporting letter to Dr G which was typed and entered
onto Webpas. That letter states "[Mr D] was also present at the
interview and his role as case manger [sic] was explained".
However, the handwritten notes made no reference to the role of Mr
81. Dr C stated no entry was made on Mr A's electronic file on 4
Month4 because he had not yet completed a full assessment (he
intended see Mr A again to complete the assessment on his return
from holiday) and he had agreed to show Mr A his final report in
draft form first. However, in contrast, Dr C also stated in
response to my provisional opinion "Doctors do not write in the
electronic notes system". Dr C said the handwritten notes were
available on the paper file and Mr D was aware of the clinical
82. Dr G did not receive Dr C's psychiatric outpatient clinic
report letter until 6 Month5 2010, two weeks after Mr A's death. Dr
C stated to HDC "there was a delay in the dictation of the report
for the GP but no delay in providing a clinical record. There were
hand-written notes available in the file … I do routinely use
hand-written notes for acute psychiatric assessments … I am not
aware of any situation where hand-written notes of clinical
information is an unacceptable practice."
83. The BoPDHB standards for documentation in health records are
contained in the "Health Record - Content and Structure Policy
2.5.2, protocol 2". This states that each entry must be legible and
complete and include accurate date and time, full signature and
designation of the health professional. No blank spaces are to be
left in any section. If a space is not completed, a line must be
drawn through the space across the section and this must then be
signed and dated. Documentation is required to be completed as soon
as practicable after any event/interaction with the patient. If any
information cannot be recorded, reasons for this must be
84. The hand-written notes were recorded on a standard
psychiatric assessment form. The copy supplied to HDC is not dated
or signed by the author. There is no indication of who else was
present at the interview besides Mr A. There is no "working
diagnosis" documented. Under "Action plan" the only entry made is
"Group → disclosure. [Quetapine]??". On the final page is written
"F/U 1. → Copy of letter. 2.→ F/U 1/12". There is no mention of Mr
D or his role, and no effective crisis plan.
85. In his response to my provisional opinion, Dr C informed HDC
that the date, time and who was present was recorded on his "clinic
list" and therefore he had "no need to transpose this important
information to my assessment form as this would be duplication of
known and already documented information." The clinic list he
refers to is a computer generated appointment schedule for the
Adult Mental Health "Clinic for [Dr C]" of "Fri 04 [Month4] 2010 at
09:30". Mr A's name is typed in the 9.30am appointment slot and the
capital letters "[of Mr D's initials]" are handwritten alongside,
but no name is stated. However, Dr C stated "[The clinic list]
clearly identifies, time, date,
doctor and case manager."
86. Dr C informed HDC that he and reception each hold a copy of
the clinic list. When the patient arrives, the receptionist
identifies the psychiatrist and case manager, and informs both.
However, Dr C's clinic list for 4 Month4 2010 was not attached to
the handwritten assessment or filed anywhere in Mr A's paper
clinical record. There is no electronic (Webpas) record, either on
Mr A's "patient visit list" or on Dr C's outpatient clinic list, of
Mr D or anyone else being present, or of Mr A having a case manager
87. Dr C further stated that he does not routinely sign his CMH
assessments as he is the only doctor on his team and the written
summary is always replaced by the dictated summary on the file. Dr
C advised that in Mr A's case, "There was no clinical reason to
inform the GP or PACT immediately as there was not [sic] acute
crisis evident" and that "I did discuss a crisis plan in detail as
I do with all my patients where relevant."
88. Mr D said he was aware that Dr C had made hand-written
notes, but was not aware that Dr C did not enter his report onto Mr
A's electronic record until 29 Month4. Mr D did not make any record
of the assessment or of his role as first point of contact on
89. In its response to my provisional opinion, the DHB advised
that, "As the second health care professional, regardless of
whether he had clarified his on-going case management role, [Mr D]
was required to adequately document his contacts with [Mr A]."
90. Dr C told HDC that, as doctors do not write in the
electronic notes system, "it was not helpful that Mr D did not
write notes on Webpas after the assessment". He stated, "There was
an electronic date on Webpas confirming my appointment and I
expected the Case Manager to document the outcome of our assessment
of [Mr A]." Dr C further stated that, regardless of case management
assignment, he expected Mr D to document notes in Webpas, as the
other health professional present at the assessment.
91. As a result, while Mr A's "patient visit list" on his Webpas
file showed he had attended an outpatient visit with Dr C on 4
Month4, the only clinical record of this assessment was Dr C's
undated, unsigned, hand-written notes on the paper file.
Furthermore, there was no record anywhere on Mr A's clinical
records of Mr D having been present at the assessment or having
been assigned as the CMH point of contact should Mr A present in
PACT contact with Ms B
92. Ms B said that in the weeks following his discharge from ICU
on 28 Month2, Mr A again stopped taking his medication, his mood
deteriorated and his aggression escalated. Ms B said she contacted
Dr G and was aware the GP was trying to refer Mr A back to CMH.
93. Ms B said that by mid-Month4, Mr A got "really scary" so she
left the house and stayed with a girlfriend. Ms B said that when
she told Mr A she was leaving, he threatened to kill himself and
she believed he would carry through with the threat.
94. Mr A's GP records state that Ms B presented to the practice
"in crisis" at 2:15pm 15 Month4 2010, reporting that Mr A had
become profoundly paranoid and disinhibited, verbally abusive and
was threatening to physically abuse her. She was advised to leave
the house and keep herself safe, to ring the Police for assistance
and to immediately notify the crisis team.
95. Ms B said she went to two Police stations "begging for
assistance", but found the Police "belligerent" and nothing
happened. She approached the PACT three times, on three separate
days, although only two of these occasions, on 16 and 17 Month4
2010, are documented. The other visit
was not documented by the PACT staff as it was categorised as a
general information enquiry from a member of the public about
Asperger Syndrome. On each visit, Ms B was seen by two PACT nurses
(involving a total of four staff members). Mr E, a registered nurse
(RN) and duly authorised officer for a sector team, spoke with Ms B
on all three occasions.
96. The exact nature of what was said at these visits remains in
dispute. Ms B said that on each occasion, she told the PACT that Mr
A was suicidal and asked for him to be assessed. She stated that
she told them that Mr A had discontinued his medication and was
unwell, but the nurse, Mr E, kept "stonewalling" her and said "why
don't you kick him out?" She said Mr E told her to get a Trespass
Order, but she didn't feel this had anything to do with the issue.
Ms B said she went to the PACT because she needed help with Mr A,
and stated "the accommodation - I could sort that out. But I
couldn't sort out his mental problems."
97. Dr G advised HDC that, when he called the PACT, he was told
"that woman has been ringing all weekend".
98. Mr E recalls that on 16 Month4, Ms M asked Mr F and him to
see Ms B. Mr E said that Ms M informed them that Mr A was not
currently a client of CMH as a recent GP referral had been
declined. Apparently no one in the PACT noticed on Mr A's
electronic Webpas "Patient Visit List" that Mr A had attended an
outpatient appointment with Dr C on 4 Month4 2010, and the PACT did
not access Mr A's paper file, which contained Dr C's handwritten
99. Both Mr E and Mr F had reviewed Mr A at the respite facility
in Month2. The PACT records from 16 Month4 document that Ms B told
the PACT that Mr A was not taking his medication, had thrown a
clotheshorse outside, and had the TV up loud. Ms B told the PACT
she had already been to the Police. Mr E and Mr F gave advice about
trespass and how to serve a trespass notice, because they
considered Ms B's concern was "about how to remove an abusive man
from her home". Ms B was given the PACT 0800 phone number and Mr E
told her the PACT was available for Mr A should he request
100. Mr E and Mr F returned to the PACT office and
discussed their findings with Ms M and the information was
discussed again at the 3pm handover meeting, to ensure the entire
team was aware of Mr A's possible deterioration should he be
101. Mr E recalls that the second PACT contact with Ms B
was similar. His notes from 17 Month4 2010 record:
"Discussion with [Mr A's] landlord [Ms B]. She came requesting
that we take [Mr A] from her home and find him accommodation in a
caravan park. A long discussion ensued again around [Mr A] making
threats to [self harm] once again should she make him leave her
home. [Ms B] has given [Mr A] to Sunday 20th [Month4] to
find alternative accommodation ... Once again we informed [Ms B]
that [Mr A] can contact at any time for support but in the past he
has made it clear that he has no faith in the mental health system.
Currently he is distressed at the ending of his relationship and
being asked to leave his place of residence. There is no current
evidence [of] psychotic illness and when the police attended
yesterday he denied any imminent intention to self harm".
102. Mr E recalls that, because this was the second
approach to the PACT with concerns about Mr A's risk in two days,
they had a long discussion about the case at the PACT handover. The
team agreed with Mr E's assessment that the case should be taken to
the sector MDT for discussion of Mr A's ongoing management. This
occurred the following morning.
103. All active PACT work is discussed at the daily MDT
meetings, at which all staff, including psychiatrists, are present.
Mr E stated that the MDT discussion is a "core process for safety
of the PACT team" and the only timetabled direct medical input for
104. The DHB's investigation report states that the
contact between the PACT and Ms B was discussed at the CMH meeting
on 18 Month4 2010. It states: "PACT became aware that [Mr A] had a
case manager and as a consequence he was taken off the PACT case
load" and that the MDT confirmed that Mr A did not require an
immediate assessment. The report states: "The meeting was informed
that an assessment was in the process of being done by a
psychiatrist and a case manager was designated".
105. Mr E stated that from 18 Month4 2010, the CMH sector
MDT assumed responsibility for Mr A's ongoing care. Mr E said "I
had no further discussion about [Mr A] and assumed that [Mr D] had
been appointed as case manager and assumed he would follow up".
106. Mr E also stated that on 16 and 17 Month4, he was not
aware that Mr A had a case manager appointed. Mr E commented that
if he had been aware of this, "PACT would not have become involved
in this case as [Ms B] would have been appropriately directed to
discuss her concerns with the case manager by the intake
coordinator." Mr F also stated that he was not aware that Mr D was
the case manager.
107. Mr E said he was also unaware that Dr C had conducted
an assessment of Mr A on 4 Month4 2010 and said they "were in fact
told that [Dr C] had declined the referral." Mr E stated:
"If we had been aware that a recent assessment had been
conducted we would have accessed that assessment and included that
in our decision making process. I would also assume that [Dr C]
would have with his formulation outlined a treatment plan with some
indication of the shape of the treatment pathway to follow".
108. A few days later, Ms B rang Dr G's surgery to request
a home visit for Mr A and was told to call the PACT. Dr G's
practice nurse contacted the PACT and the information was passed on
to Mr D, who phoned the house, but got no answer. Later that
morning, Ms B went to the house to check on Mr A and found him
dead. The Police notified the PACT of Mr A's death.
109. On 20 Month5 2010, Ms B made a complaint to the
BoPDHB Mental Health Service. An investigation was commenced by
BoPDHB, and a meeting held on 30 Month5 2010 between Ms B, her
support person, the Clinical Co-ordinator of CMH, and the Acting
Associate Director of Nursing. In response to her complaint, Ms B
was advised by the DHB that "[Mr A] was discharged from [the]
Hospital in a manner appropriate to the information available to
staff at the time".
110. The DHB conducted a Sentinel Investigation into Mr
A's case. It found that while there were administrative processes
in CMH that resulted in poor communication at times in regard to Mr
A's assessment and treatment, these did not contribute to Mr A's
suicide. Recommendations arising from the Sentinel Investigation
- to conduct staff education about serious personality
- to include reasonable explanation and guidance on ongoing
management in letters to GPs declining referrals;
- to complete all assessment documentation within required
timeframes and prior to the assessing clinician taking leave;
- to ensure clinicians' roles are clearly identified, documented
and available to all service staff in the event of an
Changes implemented by providers
111. Dr C informed HDC that he now dictates a brief
synopsis of his assessments for GPs with the statement that a
comprehensive report will follow. He noted that in practice it is
uncommon for him to require two assessments to reach a clear
112. Mr D stated that it may have been of benefit for Dr C
or him to have documented on the clinical file that the assessment
process had not yet been completed and the date planned for
completion. He further indicated the importance of highlighting to
the team when the period of assessment is continuing and when a
person is acting as point of contact only, prior to a case manager
being allocated. He stated that, with hindsight, it may have been
best for all contacts to be directed to the PACT during this
interim period, prior to case manager allocation.
113. BoPDHB has informed HDC that since the internal
investigation into this complaint the following actions have been
- A proposed change to Referral Protocol [MHAS A1.43] - Where the
referrer does not accept an initial decline of the referral, the
patient will be offered a full assessment to establish whether all
the information about the referral was captured, in order to inform
any decision to follow up.
- Proposed changes to the mental health service discharge process
[MHAS A1.31] - when patients are discharged, it will be specified
who will be responsible to engage with them when they represent
again, and what the assessment expectations will be if this happens
within a specific timeframe of 4 months or thereafter, including
how the acuteness of the presentation will influence the
- A review of the CMH Intake Co-ordinator role and the total
process of referral triage, assessment and allocation. This has
resulted in a discussion document and draft proposal which is
currently out for consultation.
- Staff education programmes about the assessment and management
of patients with serious personality disorders (by [doctor from]
University of Auckland) occurred on 15-16 September and 24-25
- A nurses' working party review with clarification of the roles
and responsibilities involved in case management as distinguished
from a request to be a second health professional attending an
appointment (as is customary practice for safety reasons when
meeting a service user for the first time). The Nurses Forum
established that the second health professional will be expected to
document the nature of their role.
114. BoPDHB accepted the factual accuracy of my
provisional report. It acknowledged that there were a number of
systemic issues resulting in deficiencies in care co-ordination
between CMH, PACT, C-L, Dr G and Ms B. It advised that the
complaints about Mr A's case have been sentinel events for the
mental health service and staff and that a number of change
management projects are currently underway to improve acute
response, embed the CAPA (Choice and Partnership Approach) model
and strengthen the NASC (Needs Assessment and Service
Co-ordination) functions in adult mental health services.
115. The Mental Health & Addiction Service advised
that the comment forwarded by the DHB "that it would have been
insensitive for staff to question statements in relation to the
relationship" was unsatisfactory and does not reflect the culture
of the service.
116. The DHB acknowledged that Mr A's discharge from ICU
by the C-L psychologist lacked input from the psychiatric
consultant or Ms B, and that this "discharge from mental health"
lacked communication with, or input from, CMH, who had been
instrumental in arranging Mr A's ED admission just two days
117. The DHB agreed that there were identified incidents
of unsatisfactory engagement with specific PACT members and that,
as a result, a review of the PACT team is underway.
118. With regard to Mr A's clinical record, the DHB
commented, "While [Dr C's] handwritten notes may have been
sub-optimal in terms of clinical documentation, they were later
transposed into an assessment that met accepted standards."
119. Ms B provided comments which have been inserted into
the information gathered where appropriate. Ms B said she is
"aggrieved that no one with a clinical background contacted her at
any stage during this saga."
120. Dr C stated that he was Mr A's doctor. However, he
also stated: "There was an electronic date on Webpas and I expected
the Case Manager to document the outcome of our assessment of [Mr
121. Dr C said he did not contact Ms B because Mr A did
not request him to do so and it would have breached Mr A's privacy
to consult Ms B without his consent. However, Dr C acknowledged
that, in hindsight, contacting Ms B at the 4 Month4 assessment
would have been wise. He advised that "I do engage with the
families/whānau of my patients and would have expected that this
would have been part of my engagement with [Mr A]."
122. Dr C stated that the 4 Month4 assessment did not
appear to him to be a crisis situation requiring an immediate
response, however, "[Mr A] was an acute risk subsequently when [Ms
B] approached the PACT." Dr C noted that "[f]urther risk is a
dynamic concept and all mental health clinicians are aware that
risk can change quickly" and that "RN [Mr E] did not need my
assessment to do an updated risk assessment and respond to [Ms B].
He was able to do this as a part of his own process. He had
available to him the electronic record of CMH contact and the paper
123. Dr C stated that he does not accept that there was
any failure in communication with Dr G following the 4 Month4
assessment. He stated, "There was an acceptable delay as a result
of clinical indictors (no new information, no crisis, no change to
his treatment) and the practical issues outlined which enhanced
engagement at the price of incompletion of the assessment … [Dr G]
wanted [Mr A] seen in CMH. He did not state any particular purpose
and he did not ask for any specific treatment."
124. Mr D reiterated:
"I still dispute that case management was discussed and would
like it noted … it was clear from the [4 Month4] assessment that no
critical need for case management was identified, therefore no case
manager was appointed. This is my rationale and supporting evidence
for not proactively engaging with [Mr A] … As point of first
contact there was no onus on me to 'initiate contact' but should
[Mr A] request contact, he could request me by name."
125. Mr D submitted that he was not asked by Dr C to be
more than a point of contact after the first part of the assessment
was completed and that the information provided by Mr A "did not
126. Mr D observed that there is "a lack of clarity around
the role of the second health professional/observer and when the
intervention of case management should start … This leaves 'case
managers' in a precarious situation with regard to expectations
placed upon them." He further commented, "I have had almost two
years to reflect on my practice since that event and feel that my
only failing was not documenting that I was point of contact and
that the assessment was incomplete."
NATIONAL MENTAL HEALTH SECTOR
RECORDS AND CONFIDENTIALITY
An accurate and confidential record that promotes efficient and
effective delivery of treatment and support is maintained for each
person receiving the service.
People receiving the service have an individual record including
relevant and necessary information about their treatment and
support in order to meet the requirements of The National Mental
Health Sector Standard. The requirements for individual's records
shall be recorded in the organization's policies and
Individual records are comprehensive, objective, factual and
accurate, and provide a sequential record of the involvement with
the service. Each entry in the individual clinical record is dated,
signed (including designation) and is legible.
This shall include and is not limited to ensuring:
(a) Paper or computer records are unique to each person
receiving the service within which their current status under any
relevant legislation is clearly identifiable;
(b) Regular file auditing.
Each person who receives the service has access to his or her
individual record in line with legislation.
A system exists by which the mental health service uses the
appropriate information about the person who is receiving the
service to ensure continuity of treatment and support for the
individual. The record can be readily accessed for use in any
contact with the service.
This shall include and is not limited to:
(a) A single record for each person who receives the service
(this includes electronic records);
(b) Policies and procedures ensure that relevant and
necessary information about the people who receive the service is
shared between providers, and across all components of the service
including inpatient and community.
FAMILY, WHĀNAU PARTICIPATION
The mental health service has policies and procedures relating
to family, whānau participation, which encourages their appropriate
involvement in the service.
This shall include and is not limited to:
(a) Ensuring the privacy,
confidentiality and rights of any person receiving the service is
not infringed as part of this process.
LEADERSHIP AND MANAGEMENT
The governing body ensures there are effective communication
systems and working relationships in order to facilitate the
delivery of co-ordinated services. This should occur within and
across the mental health service, and with other relevant
organizations and individuals.
Following assessment each person and their family, whānau, with
their informed consent, is provided with information on the
diagnosis, options for treatment, support, or referral and possible
QUALITY TREATMENT AND SUPPORT
The identification of early warning signs and relapse prevention
is included in the individual plan. Each person receiving the
service and their family, whānau receives assistance to develop a
plan that identifies early detection or warning signs of a relapse
and the appropriate action to take.
The Transfer, Exit or Discharge Plan is reviewed in
collaboration with each person who receives the service and with
their informed consent their family, whānau."
127. Mr A was receiving services from a number of
clinicians within CMH, as well as his GP. Mr A's partner and his GP
recognised Mr A's deteriorating condition and attempted to obtain
assistance from CMH. In such a situation, effective communication,
both within the CMH team and between CMH and the GP, was essential.
Mr A did not receive the services he needed because of a
combination of individual failures and systemic factors.
128. In any healthcare system, there are a series of
layers of protections and people, which together operate to deliver
seamless service to a patient. When any one or more of these layers
do not operate optimally, the potential for that level to provide
protection, or deliver services, is compromised. When a series of
such events occur, although each are often minor in themselves, the
fabric that is wrapped around the patient in the delivery of a
seamless service is torn. When a series of tears, or holes, line
up, poor outcomes result. Patients are at risk of being harmed.
129. At the outset, it is important to note that that my
role does not extend to determining cause of death. I am primarily
concerned with the quality of care provided to the consumer and
whether that care accorded with the requirements of the Code. In my
view, the services provided to Mr A had multiple failings. A number
of people were aware of his deteriorating condition, but the
failings hampered the ability of those people who were concerned
about Mr A to access the required help for him.
Opinion: Breach - Dr C
130. Mr A had the right to receive services of an
appropriate standard from psychiatrist Dr C. This included the
right to have services that complied with professional standards of
the right to co-operation among providers to ensure the quality and
continuity of Mr A's care.
131. The typed report of Dr C's 4 Month4 2010 assessment
was not entered onto Mr A's electronic record until 29 Month4 2010.
Dr C stated that in the interim period, his handwritten notes were
available on Mr A's hard file. However, these notes are hard to
decipher and fall short of the DHB standard of clinical records
being legible, complete and compliant with generally accepted
132. The handwritten documentation contains much less
detail than Dr C's final ten-page typed record of the assessment.
There is no indication of a diagnosis or action plan besides the
note "copy of letter", and a follow-up appointment for one month.
There is no documentation of the interim crisis action plan agreed
upon. In my view, these handwritten records were not of a
reasonable standard and, even though other staff could access them,
they were insufficiently clear to be meaningful. Despite Mr A's
appointment with Dr C showing on the outpatient clinic schedule,
other clinicians would not have been able to ascertain from the
paper records when the assessment took place, who was present, and
who carried out the assessment.
133. Dr C submitted in response to my provisional opinion
that there was no need for him to enter identifying details such as
date, who was present or signature, because they were accessible
electronically on the 4 Month4 CMH outpatient clinic schedule.
However, even if the appointment had been identified on Webpas,
there was nothing on the written assessment to link it to that
electronic appointment and there was also no indication on Mr A's
file that Mr D was present or his role.
134. Dr C had handwritten Mr D's initials on his paper
print-out of the clinic schedule, but this would not have been
evident on Webpas, and its meaning is unclear. Further, I do not
find that Dr C's omission to sign his psychiatric assessment can be
justified by his being "the only doctor on the team" or that it was
his "routine practice" not to do so. Dr C's handwritten notes were
the only specialist documentation informing Mr A's care, between 4
Month4 and 29 Month4 when the typed report became available.
135. The clinical record, which may be contributed to by
numerous providers, is a historical record of a patient's medical
history. Its purpose is to inform all providers within the DHB who
provide services to that patient. It is important that other
providers are able to identify the author of clinical records, so
that person can be consulted with, or clinical information
clarified, if the need arises. Given the possibility that Mr A's
risk level might change, the crisis plan should have been evident
from the records.
136. The National Mental Health Sector Standard requires
records to be "comprehensive, objective, factual and accurate, and
provide a sequential record of the involvement with the service.
Each entry in the individual record is dated, signed (including
designation) and is legible". My expert
advisor, consultant psychiatrist Dr Murray Patton, noted that
records must inform further contact and outline the basis of
conclusions with respect to the assessment and treatment plan. He
commented that while "working notes" may sometimes be used as an
outline that informs or supplements a more concise summary, such a
summary was not completed by Dr C in a timely manner and was
therefore not available to inform care. Dr Patton has advised that
Dr C's documentation departed from accepted psychiatric standards
by at least a moderate degree.
137. I consider that Dr C's handwritten documentation of
the 4 Month4 assessment was well below that required in the
National Mental Health Sector Standard and, accordingly, Dr C
breached Right 4(2) of the Code.
Continuity of care
138. Dr C's involvement in Mr A's care commenced in Month3
2010, when Dr G's first referral of Mr A to the CMH was considered
and declined. Later that month, Dr G again referred Mr A to the
CMH. After consideration of that second referral, the MDT could not
reach a consensus on the best way forward, so Dr C decided to take
the referral to the senior medical officer peer review group for
139. Dr Patton commented that this decision was
appropriate in light of Dr G's concerns, as was the decision to
offer Mr A a timely appointment for a psychiatric assessment. That
assessment was conducted by Dr C on 4 Month4 2010, but was not
completed within the allotted time.
140. While Dr Patton considered the assessment itself to
have been adequate, he was critical of the follow-up arranged.
Firstly, while Dr Patton viewed Dr C's assessment of risk as
reasonable as far as he could tell from the records of that
assessment, he noted that risk is a dynamic concept and the most
significant dynamic factor contributing to Mr A's risk was the
quality of his relationship with Ms B. It would have been desirable
to have planned interim contact between Mr D and Mr A to maintain a
budding alliance and to assess Mr A's relationship with Ms B.
141. Secondly, Dr Patton viewed Dr C's plan for Mr A to
proactively contact the mental health service should he be feeling
distressed as 'optimistic', particularly in the absence of someone
within the service with whom Mr A had a regular relationship. Mr A
had been reluctant to co-operate with assessments after his suicide
attempts and had expressed his dislike of the CMH.
142. Dr Patton noted that on 26 Month2 2010, when Mr A had
been making threats to harm himself and Ms B, there was no evidence
Mr A had any inclination to contact the PACT, despite his distress.
On the other hand, Mr A had willingly accepted CMH contact in the
past in the context of an ongoing psychotherapeutic relationship,
such as during his 11-month period of psychotherapy with Mr J. Dr
Patton considered that Dr C would have made a clinical judgment on
whether a therapeutic alliance had been sufficiently established
between himself, Mr D and Mr A, to expect that Mr A would make
contact if distressed.
143. I note Dr C stated he did not contact Ms B on 4
Month4 because Mr A did not request him to do so. However, in my
opinion, Dr C should have asked Mr A to give his consent for the
crisis plan developed at this assessment to be communicated to Ms
B, as a further safety measure. This would have been in keeping
with the DHB's policy of involvement of whānau in patient care. Ms
B was aware of changes in Mr A's risk factors and increases in his
vulnerability. If made aware of the plan, she would have known to
go directly to Mr D for help, rather than to the Police and PACT. I
note that in hindsight, Dr C agrees that contacting Ms B would have
144. Dr C did not make a timely electronic record of the
assessment or the crisis plan. He stated that he expected the case
manager to document the outcome of the assessment. Apart from the
confusion as to whether Mr D was the case manager, in any case as
Mr A's doctor, Dr C was responsible for ensuring that his
assessment of Mr A's condition, any diagnosis, and the plan
(including the crisis plan) were clearly evident in the records. If
Dr C expected Mr D to record Dr C's opinions, he should have
clearly communicated this expectation to Mr D. I note BoPDHB has
advised me that Mr D was required to "adequately document his
contacts with [Mr A]". In my view, this requirement does not extend
to documenting Dr C's assessment.
145. The PACT nurse, RN Mr E, stated that had he been
aware of the recent assessment, the PACT would have accessed that
assessment and included it in the decision-making process when Ms B
approached them with concerns about Mr A's mental health. RN Mr E
commented that he would also have assumed that Dr C would have
given some indication of a treatment pathway to follow.
Unfortunately, as noted above, even if the PACT had accessed the
hard file, Dr C's handwritten documentation of the assessment would
have been uninformative in this regard and would have given no
indication of Mr A's crisis plan with Mr D as the first point of
146. Dr G received no report of the 4 Month4 assessment
until Dr C's letter was received at his GP clinic on 6 Month5 2010.
Sadly, Mr A had died two weeks earlier. I find this delay in
communication unacceptable. Both Mr A and Ms B remained in contact
with Dr G and he was responsible for prescribing Mr A's
psychotropic medications. Mr A and/or Ms B may have contacted Dr G
in the event of a crisis arising. In fact, on 15 Month4 2010, Ms B
did just that. In these circumstances, I believe that, at the very
least, prompt communication to Dr G that the assessment had taken
place, the risk assessment, and the interim crisis plan, was
essential for the continuity of Mr A's psychiatric care.
147. I appreciate that forging a respectful and positive
therapeutic engagement was a sound clinical reason for extending Mr
A's assessment over two interview sessions, and that it is unusual
to require more than one interview to complete a CMH psychiatric
assessment. Nonetheless, I believe such an occurrence is
foreseeable and does not justify Dr C's failure to communicate with
Dr G, at least by way of a phone call/message or brief note, rather
than intending to wait over one month before communicating with the
GP after the planned 5 Month5 appointment. This was particularly
important given the time that was to elapse between the first and
second appointments and the fact that Dr C was to be unavailable
during that period.
148. I do not accept Dr C's contention that "there was no
clinical reason to inform the GP or PACT immediately as there was
not [sic] acute crisis evident". Within the preceding six weeks, Mr
A had made two suicide attempts and had twice been referred back to
CMH by his GP. While there may have been no significant psychiatric
findings on 4 Month4, Dr C noted himself that, "Further risk is a
dynamic concept and all mental health clinicians are aware that
risk can change quickly." Dr C has confirmed that it was relevant
for him to discuss a crisis plan in detail with Mr A. In my
opinion, this was appropriate and demonstrates that the possibility
of a crisis arising sometime over the next month could be
anticipated. As such, to ensure continuity of care, I believe that
the GP and PACT should at least have been informed of the crisis
149. In my opinion, Dr C's failure to communicate with Dr
G or Ms B, together with his failure to take adequate steps to
ensure the crisis plan involving Mr D as point of first contact was
documented on the clinical record, meant that Mr A's continuity of
care was compromised. Dr C thereby breached Right 4(5) of the Code.
I note that Dr C has acknowledged these shortcomings in
communication and has made changes to his practice. These breach
findings do not imply that Dr C was responsible for Mr A's
Adverse comment - Mr D
Communication of role
150. Mr D became involved in Mr A's care when he agreed to
attend the 4 Month4 psychiatric assessment. The reporting letter
prepared by Dr C on 29 Month4 2010 states "[Mr D] was also present
at the interview and his role as case manger [sic] was explained".
However, the handwritten notes made on 4 Month4 have no reference
to the role of Mr D. Whether he attended merely as a "second
observer" or as a case manager is not certain. However, it is an
undisputed fact that he agreed to be point of first contact at CMH
for Mr A, should a crisis situation arise.
151. Mr D's role was particularly significant in Mr A's
case, given that the other clinician with knowledge of the current
assessment, Dr C, was going on leave and would not be available for
the next month.
152. Mr D's position description includes: "Works and
communicates effectively as a member of the multi-disciplinary
team, demonstrating individual responsibility and accountability".
As a registered health professional undertaking a key role in the
crisis management plan for Mr A, Mr D had a professional
responsibility to ensure that his role as the intended point of
contact for Mr A at CMH, was readily evident in the DHB information
system and/or otherwise communicated effectively to the PACT. This
information should have been available when Ms B made contact with
the PACT on 15 Month4 2010.
153. However, it appears that from 4 Month4 until 18
Month4, the only people aware that Mr D was to be the point of
contact were Mr D, Dr C and Mr A. Neither the PACT nor Dr G was
informed of Mr D's role and his role was not apparent from either
the hard file or the electronic record. This compromised Mr A's
continuity of care.
154. As stated, although Mr A was not felt to be at risk
on 4 Month4 2010, risk is a dynamic concept and it was foreseeable
that changing circumstances might change the risk level.
155. In my view, it was reasonable for Mr D to assume that
Dr C, as the lead clinician at the assessment, would record the
assessment. However, Mr D should have himself confirmed that the
crisis plan and his role in it was entered into Mr A's record or
otherwise communicated to the PACT. I am advised that it is not
unusual for psychiatrists to delegate documentation to psychiatric
nurses, particularly in circumstances such as this, where the
assessment is not yet complete, or due to time restraints, such as
where the psychiatrist is immediately going on leave. Dr C has
stated that he "expected" Mr D to document the outcome of their
assessment. However, there is no evidence that any overt delegation
occurred in this case. As a result, I do not consider a breach
finding is warranted in relation to Mr D's failing to document his
role in Mr A's care.
156. I note that had Mr D been clearly assigned as Mr A's
case manager, the BoPDHB job description of that role would have
placed clear responsibility on him to inform others of his role. I
agree with Dr Patton's observation that it is possible to see why
Mr D was variously described as being the case manager, given that
his expected role accorded with that of case management. The
referral from Dr G had been accepted by CMH. More contact was
planned. No one else was expected to have any role in that period,
as Dr C had gone on leave and was unavailable. The clear
expectation was that Mr D, as the first point of contact, would
therefore have the responsibility for making further arrangements
as needed should Mr A present to CMH. This is congruent with the
job description of a BoPDHB case manager. However, Mr D asserts
that he did not believe the case management role had been assigned
to him and there is no record in the team meeting minutes or Mr A's
clinical records that a case manager had been assigned.
157. In light of my concerns about the DHB's practices
around the appointment of case managers (discussed below), I do not
find that Mr D breached the Code for failing to fulfil the duties
required by a case manager. I do, however, regard his passivity as
Contact with Mr A
158. As mentioned above, it would have been good practice
for interim contact to have been planned between Mr D and Mr A
following the 4 Month4 assessment, to foster a therapeutic alliance
and reassess issues of vulnerability. While Dr C was clearly the
lead clinician at the assessment, I believe Mr D, as a registered
psychiatric nurse, should have taken the initiative and ensured
that Mr A had appropriate support and supervision. I note the role
of a registered nurse at BoPDHB includes:
- undertaking a timely comprehensive nursing assessment and
making nursing judgments; and
- engaging in robust ongoing assessment and management of
159. In my opinion, Mr D's absence of contact with Mr A
following the 4 Month4 assessment fell below this standard. I
interpret "robust ongoing assessment" as setting an expectation of
proactivity on Mr D, rather than passively waiting for Mr A to make
contact with the service should his condition worsen. It seems this
lack of proactivity accorded with Mr D's narrow view that he had a
passive role as the second observer to an assessment. In my view,
Mr D should reflect on his lack of initiative in this case.
Opinion: Breach -
Bay of Plenty District Health Board
160. A number of BoPDHB departments provided care to Mr A
including ED, ICU, C-L psychiatry, CMH outpatients and the PACT. In
providing this care, the BoPDHB had a duty to ensure quality and
continuity within and across these services, and with external
parties involved in Mr A's care, such as Dr G and Ms B. This was
essential to ensure that Mr A was provided with seamless care of an
appropriate professional and organisational standard.
161. In Month4 2010, there were failures in co-ordination
between Mr D, Dr C and the PACT staff. The role of Mr D was
unclear, the records of prior contacts with Mr A were not
adequately accessed and, when situations arose which resembled
those which had previously increased Mr A's vulnerability to
self-harm, they were not adequately responded to.
162. Criteria 12.3 of the National Mental Health Sector
Standard requires the DHB to ensure there are effective
communication systems and working relationships in order to
facilitate the delivery of co-ordinated services within and across
the mental health service, and with other relevant organisations
163. Dr Patton advised that "overall, the care was
patchy". While some things were carried out well, others could have
been improved, and there were several areas where Mr A's care fell
below expected standards.
Service delivery - missed opportunities
164. Dr Patton has advised that the DHB psychiatric
assessments performed by Dr I, Dr K, Ms L and Dr C were all of
reasonable standard. However, he identified suboptimal aspects of
the PACT care, which were of some concern.
165. On 22 Month2, when the PACT staff assessed Mr A in ED
following his first suicide attempt, they did not document a mental
state examination. It appears the examination may have been limited
by Mr A having terminated the assessment. However, despite the
documented plan to "reassess mental state tomorrow", when the PACT
staff visited Mr A at the respite facility over the following days,
only cursory attention to his mental state was recorded, with the
assessments predominantly focused on whether Mr A had suicidal
166. In my opinion, optimal practice should have seen the
visiting staff continuing their follow-up by attempting to explore
whether Mr A had a mental disorder through systemic enquiry of his
symptoms and a comprehensive mental state examination. I accept
however, that arranging for a specialist review within a few days
(by Dr I) was reasonable and that there was no evidence of acute
mental illness reported by respite facility staff to the PACT.
167. Of greater concern however, is the PACT's interaction with
Ms B in Month4. Between 15 and 17 Month4 Ms B contacted the PACT
three times. It is documented that she was seeking information
about to how to remove Mr A from her home and that he was
threatening suicide and behaving in a threatening manner. The PACT
provided practical information to Ms B. However, the implications
of this eviction for Mr A do not appear to have been adequately
considered by the various PACT staff.
168. As confirmed by BoPDHB, the PACT staff, as senior
nurses and duly authorised officers, were expected to access Mr A's
health record and prior service contacts and respond accordingly.
Mr A's recent appointment with Dr C was noted on Webpas but this
was evidently missed by the PACT triage co-ordinator and the PACT
duly authorised officers. On 18 Month4, the MDT decided that Mr A
did not require an urgent assessment and noted that a psychiatrist
was in the process of assessing Mr A and that a case manager had
been appointed in the interim.
169. Mr A's vulnerability at times of relationship stress and
eviction was known to the service, and these had been clearly
documented in his clinical record as risk factors which had
precipitated his previous suicide attempts. In my opinion, the
warning signals were not responded to appropriately.
170. These circumstances should have prompted the PACT
staff to contact Mr A directly for assessment and review,
particularly on the second occasion that Ms B presented informing
them Mr A was threatening suicide.
171. I am also critical of the PACT's apparent reliance on
the Police's assessment of Mr A in its decision-making,
particularly in the absence of any direct communication with Police
on the issue. On 17 Month4, a PACT duly authorised officer, RN Mr
E, spoke to Ms B and, as a result of information she provided,
recorded "there is no current evidence [of] psychotic illness and
when police attended yesterday he denied any imminent intention to
self harm". RN Mr E did not speak directly to the Police.
172. In my opinion, any conclusions drawn by the PACT
about Mr A's mental state and suicide risk, should have occurred
through direct contact and assessment of Mr A by PACT staff
themselves. Dr Patton commented on this issue:
"[R]elying on information from people untrained in assessment of
mental state or risk of self-harm in making a determination that
there is no evidence of grounds for immediate concern, especially
when there is no direct contact between the clinician and the
person upon whose assessment reliance is being placed, is
fundamentally flawed practice. In circumstances in which it could
reasonably be assumed that there was an increased risk, which was
acknowledged by the PACT staff, making a more active arrangement to
directly review the person who might be at risk should be
considered and options to do this should be explored." 
173. For the reasons above, I find the PACT's and MDT's
inadequate responses when provided with information indicating that
Mr A was experiencing a crisis meant that Mr A was not provided
with services with reasonable care and skill, amounting to a breach
by BoPDHB of Right 4(1) of the Code.
Continuity of care
Communication with Ms B
174. A further concern is the DHB's lack of consultation
with Ms B about Mr A's care and discharge planning. Mr A had been
estranged from his family for several years. His only significant
personal relationship was with Ms B, who is variously described in
Mr A's DHB clinical record as his flatmate, girlfriend, partner and
175. The National Mental Health Sector Standards require
that patients and, with consent, their families or whānau, are
provided with information on their diagnosis, options for
treatment, support, or referral and possible prognosis. Similarly,
discharge plans should be reviewed in collaboration with families
176. On 23 Month1, Ms B moved out of her house as she
could not cope with Mr A's behaviour. On 22 Month2, it was noted Mr
A's suicide attempt was precipitated by the relationship break-up.
Ms B refused to allow Mr A to return to her house when he was
discharged from ED. On 26 Month2, Ms B made a phone call to the
DHB, requesting that Mr A's belongings be collected from her
garage. None of these events suggest her relationship with Mr A was
back on good terms or that she was expecting him to return to live
177. On 27 Month2, there is mention in the records that Mr
A was visited by his "girlfriend". This, together with Mr A's own
statements, seems to have been the basis for the PACT's and Dr C's
assumptions that the relationship issues had resolved and Mr A's
accommodation with Ms B was now stable. However, no steps were
taken to obtain Mr A's consent for staff to contact Ms B to discuss
or confirm these facts, despite the well-documented connection
between relationship separation and Mr A's mental state and his
clinical notes indicating that Ms B was happy to be contacted by
mental health staff.
178. I find the DHB's statement that "it would have been
insensitive for staff to question [Mr A's] statements that the
relationship had resolved and that he was returning to his
address", to be unsatisfactory. It is reassuring to note that
BoPDHB has since agreed that the comment was unsatisfactory and
does not reflect the culture of the service. The importance of good
working relationships between mental health workers and family,
particularly when a patient is being discharged from the DHB
service, has been emphasised in previous HDC Opinions and is recognised in
National Mental Health Sector Standards, which encourage family
involvement with the patient's consent.
179. I note BoPDHB's policy requires the discharge plan to
be developed collaboratively with the patient and family/whānau; to
identify and manage risks associated with the discharge including
expressed concerns of the family/whānau; and for arrangements to be
satisfactory to the patient and their family/whānau prior to the
discharge. Ms B was effectively Mr A's only 'whānau' at the time
and was intrinsically involved in his identified "dynamic risk
factors" of relationship and accommodation issues.
180. In my opinion, it was not good practice for the DHB
to plan Mr A's discharge from the mental health service on 28
Month2 on the basis of unverified facts suggesting that his
relationship and accommodation-related risk factors had resolved.
Moreover, it was unreasonable for the DHB to fail to take
appropriate steps to obtain Mr A's consent to discuss the plan to
discharge Mr A to Ms B's home with her. Given Ms B's known concerns
about Mr A residing in her home and that difficulties in his
relationship were a risk factor for him, the DHB should have
verified the circumstances. By failing to ensure staff sought Mr
A's consent to involve Ms B in Mr A's care and discharge planning,
BoPDHB did not comply with the National Mental Health Sector
Standards and the organisational standards of discharge planning
and breached Right 4(2) of the Code.
Communication with Dr G
181. Ms B contacted the PACT on 23 Month1 2010, expressing
concern that Mr A was unwell. Although the Mental Health Act
(Compulsory Assessment and Treatment) Act 1992 (MHA) was discussed
and Ms B was advised to consult Mr A's GP, the PACT did not contact
Dr G directly.
182. Dr Patton advised that optimal clinical practice
would have been to alert Dr G, so that he was aware of these
background events should Mr A present to his practice. This was
particularly important when the possible use of the MHA was being
discussed. In Dr Patton's view, the omission to contact the GP in
this circumstance would be viewed with disapproval by peers,
although he noted that it is unlikely to have had any material
effect on Mr A's care. In my opinion, the failure by the PACT to
notify Dr G detracted from optimal continuity of care being
provided to Mr A.
183. When Mr A was discharged from ICU following his self
harming during Dr I's assessment on 28 Month2 2010, there were
apparent inconsistencies in the follow-up plans communicated to Dr
G between the medical discharge letter and the mental health
discharge letter. The medical discharge summary suggested further
psychiatric outpatient care would be forthcoming, but the C-L
psychologist's letter to Dr G, made it clear no further planned CMH
care would be offered. The C-L decision to "discharge from mental
health" was apparently made without communication or input from CMH
who had arranged Mr A's admission only two days prior. In my
opinion, this discharge planning is another instance of poor
co-ordination and continuity of patient care.
184. Dr G's referral of Mr A back to the DHB's mental
health service on 5 Month3 2010 was considered at the
multidisciplinary team meeting on 11 Month3. I note Dr G explained
his letter was somewhat brief as he assumed it would be considered
in conjunction with the service's knowledge of Mr A's "compendious"
past history. The DHB sentinel investigation report suggests that
the team considering the referral would not have been aware of his
prior history of high-risk behaviours, as a different team had
previously managed Mr A's care. This statement is difficult to
reconcile with the DHB's standard practice of obtaining prior
records when considering what action to take in respect of a
185. Mr A's prior history should have been obtained by the
intake co-ordinator and been available to the team. I find it
concerning that there was a breakdown in this process, and that the
intake co-ordinator did not access Mr A's records. A lack of
information-sharing within a DHB clearly has negative implications
on continuity of patient care. This may also go some way to explain
the CMH's difficulty in assessing Dr G's referral.
186. Dr G's first referral was declined by the intake
co-ordinator's letter dated 11 Month3, which stated that the
criteria for entry to the service were not met. Dr Patton advised
that the referral was declined on reasonable grounds (that there
had been several recent assessments and the GP referral letter
contained no indication of change in Mr A's condition). However,
optimal practice of the CMH team at this time would have been to
have had a direct discussion with Dr G about the reasons for
declining the referral.
187. I consider that in cases where CMH perceives
difficulty with a GP referral, it should contact the GP directly to
clarify the reasons for and expectations of the referral, to
confirm any key facts (such as the relationship and accommodation
status in Mr A's case) and to address any specific concerns
relating to the assessment outcome. In this case, such direct
discussion would have allowed Dr G to provide further information
to assist with consideration of the referral.
188. On 14 Month3, when Dr G referred Mr A to CMH for a
second time, expressing astonishment and frustration at the initial
referral being declined, again no-one from CMH contacted Dr G
directly. Dr C commented that the referral letter contained a "lack
of information on which we could make an informed decision". Dr C
was unclear "who actually wanted the assessment and for what
particular reason", and the MDT was unable to reach a consensus on
handling the referral.
189. I note the DHB has a policy that if a referral is not
comprehensive, the intake co-ordinator will contact the referrer to
gain further information to clarify the appropriateness of the
referral and the urgency with which it should be handled. In my
opinion, this policy should have been followed.
190. It seems clear from the promptness of his re-referral
that Dr G had significant concerns about Mr A, notwithstanding the
brevity of his referral letters. A phone call to Dr G could have
clarified his concerns, provided him with management advice, and
would have been an excellent opportunity for CMH to provide
constructive feedback to him regarding the information required
when making future referrals. I believe the absence of direct
communication between Mr A's primary and secondary providers in
these circumstances indicates a failure in the implementation of
the DHB's referral handling process, which also was detrimental to
the quality and continuity of Mr A's care.
191. CMH appears to have lacked insight into and
acknowledgment of the importance of Dr G's role, which had
implications for the continuity of Mr A's care.
Communication within the DHB
192. Dr Patton advised that the eventual decision to offer
a specialist assessment was appropriate. However, he viewed the
apparent failures in co-ordination within CMH subsequent to this
with, at least, moderate disapproval.
193. The plan for Dr C to conduct a CMH outpatient
psychiatric assessment was made at the senior medical officer peer
review group. I am concerned that this plan was apparently not
communicated to other key members of the CMH team, including the
intake co-ordinator Ms M, who had responsibility for triaging and
processing referrals. Ms M had triaged both referrals from Dr G.
She had written the letter to Dr G declining the first referral. Ms
M was the intake co-ordinator when Ms B presented to PACT in
Month4. Ms M erroneously believed that Mr A's care had been
declined by the service. This misinformation was taken into account
in the PACT's decision-making about Ms B's visits.
194. I consider the communication between the staff
involved in the referral handling process was deficient. If Ms M
had known Mr A had been assessed by Dr C on 4 Month4, she would
have been in a position to investigate the outcome of the
assessment when Ms B presented on 15 Month4, and if she found no
electronic record of it, she could have accessed Mr A's hard
clinical file. Unfortunately this would not have disclosed the
crisis plan detailing the role of Mr D as the first point of
contact, but would have enabled the PACT staff to be made aware of
Dr C's recent assessment of Mr A.
195. The misunderstanding of Mr D's role in Mr A's care
was a further example of poor communication processes within the
DHB's mental health service. The process for case manager
appointment was that the case manager could be appointed at the MDT
meeting or during the referral process. Any subsequent
documentation was completed by the case manager. As a result, there
was no check that the person appointed was aware of their role. In
addition, there was no record of Mr D's role in the team meeting
minutes or in Mr A's records.
196. Mr D stated that he did not consider he was involved
in the management of Mr A, and was simply an observer at the 4
Month4 assessment and a point of contact while Dr C was away. This
is at odds with Dr C's understanding and underscores my view that
the process of case management allocation was deficient.
197. In addition, while the DHB has indicated that it
expected Mr D to have documented his contacts with Mr A, my
investigation did not find any clearly defined role/expectations of
the second 'observer' health professional present at a BoPDHB CMH
assessment. It is important that the role and expectation of each
team member is made clear at the time a role is allocated and that
these roles are made clear to others.
198. BoPDHB failed to contact Mr A for further assessment
following Ms B's visits to the PACT between 15 and 17 Month4 2010,
when his increased risk factors for self-harm were known and
identified. Accordingly, I find that BoPDHB did not provide Mr A
with services with reasonable care and skill and so breached Right
4(1) of the Code.
199. BoPDHB failed to take appropriate steps to discuss the
discharge plan with Ms B and so did not comply with the National
Mental Health Sector Standards and the organisational standards of
discharge planning. Accordingly, I find that BoPDHB breached Right
4(2) of the Code.
200. BoPDHB also failed to ensure continuity of care for Mr A.
Of most concern was the failure in co-ordination between Mr D, Dr C
and the PACT staff in Month4, when the crisis plan of Mr D as
intended first point of contact was not made known to the PACT.
201. Other inadequacies in the flow of information and
communication within the DHB are demonstrated by the
misunderstanding between the medical team and psychiatric liaison
service as to psychiatric outpatient follow-up; the fact that the
CMH team considering the first GP referral was not aware of Mr A's
prior history; the failure to inform Ms M of Mr A's acceptance for
CMH assessment on 28 Month3; and the confusion about whether Mr D
was appointed case manager. BoPDHB also failed to communicate
adequately with Dr G after Ms B's visit to the PACT in Month1 2010,
and when processing his two referrals to CMH in Month3 2010. The
failures in co-ordination between CMH, the PACT and Dr G impaired
Mr A's continuity of care. Accordingly, I find that BoPDHB breached
Right 4(5) of the Code.
Comment on changes made by BoPDHB
202. I am not able to comment on any changes in respect of the
Referral protocol and Discharge from MH&AS protocol reviews, as
I have been advised by BoPDHB that these are on hold pending the
review of the intake co-ordinator role.
203. BoPDHB has advised me that education sessions aimed at
improving staff knowledge and expertise in dealing with patients
with serious personality disorders have taken place. However, I
agree with Dr Patton that education should be accompanied by
ongoing support for implementation of the learning and practice
204. The DHB pointed to the expectation, as established at the
nurses' forum, that a second health professional at an assessment
will document their participation. However, I note Dr Patton's
further advice that unless the practice is backed up by ongoing
audit and supervision, this somewhat "soft" approach to practice
improvement is likely to have only limited effect.
205. I recommend that BoPDHB:
- review its operating procedures and polices in light of this
report and provide HDC with evidence by
31 October 2012 of changes made, staff training,
and planned follow-up/audits, in respect of:
- The CMH referral handling process; specifically addressing
direct communication with referrers, and internal communication of
2. The triage/intake co-ordinator role, including the
requirement to access prior records, and direct communication with
3. The training of mental health staff regarding discharge
planning, and the involvement of whānau/family and other
4. The case management allocation process, documentation and
training to ensure clarity of team members' roles.
5. Clarification of the role and expectation of health
professional/s taking part in assessments.
6. Ongoing education and staff support relating to the
management of patients with severe personality disorders.
- provide a written apology to Ms B for its breaches of the Code.
The apology is to be forwarded to HDC by 15 October
2012 for sending to her.
206. I recommend that Dr C:
- provide a written apology to Ms B for his breaches of the Code.
The apology is to be forwarded to HDC by 15 October
2012 for sending to her.
- undertake training on the DHB documentation standards protocol
"Health Record - Content and Structure Policy 2.5.2, protocol 2"
and provide HDC with evidence by 15 October 2012
of training having been undertaken, and report to HDC any changes
made to his practice.
- A copy of this report will be sent to the Coroner.
- A copy of this report with details identifying the parties
removed except the DHB and the expert who advised on this case,
will be sent to the Medical Council of New Zealand and the Nursing
Council of New Zealand. The Medical Council of New Zealand will be
advised of Dr C's name and the Nursing Council of New Zealand will
be advised of Mr D's name.
- A copy of this report with details identifying the parties
removed, except the DHB and the expert who advised on this case,
will be sent to DHB Shared Services, the Royal Australian and New
Zealand College of Psychiatrists, and the New Zealand College of
Mental Health Nurses.
- A copy of this report with details identifying the parties
removed, except Bay of Plenty DHB and the expert who advised on
this case will be placed on the Health and Disability Commissioner
website, www.hdc.org.nz, for educational
Appendix A - Independent expert
psychiatric advice to the Commissioner
The following expert advice was obtained from Dr Murray Patton,
[Mr A] / Bay of Plenty DHB
Your ref: 10/0805
Thank you for your letter of 29 August 2011. You have asked me
to provide advice in respect of this complaint about the
psychiatric care provided to [Mr A] by the Bay of Plenty DHB
(BoPDHB), further to the preliminary advice that I provided to you
on 2 May 2011.
You are seeking my view about whether the BoPDHB, including [Dr
C] and [Mr D] specifically, provided a reasonable standard of care.
In addition you are asking whether there are any aspects of the
care, systems or decision-making processes involved in this case
that warrant additional comment or recommendations for
You have also asked me to comment on the changes implemented by
the DHB in response to this complaint.
I cannot identify any conflict of any nature in providing you
with advice on this matter.
You have provided me with supporting information bundled
together in 2 files. Your letter identifies this supporting
information as being:
- Clinical notes from BoPDHB (complete file as supplied to HDC);
pages 1 to 439
- Copy of complaint; pages 442 443
- Record of phone call with [Ms B], 9 August 2011; pages 444 to
- [Dr G's] report to the coroner; pages 448 to 460
- BoPDHB response to the complaint, 18 November 2010, including
the DHB complaint file (pages 464 to 493) with Sentinel
investigation report (pages 494 to 504)
- Copy of my preliminary advice to HDC, paragraphs numbered as
supplied to the providers; pages 505 to 515
- Response to notification of investigation from [Mr D], dated 30
June 2011; pages 516 to 530
- Response to notification from [Dr C], dated 28 July; 2011 pages
531 to 542
- Response to notification from the BoPDHB dated 8 July 2011;
pages 543 to 823
Was the care that was provided to [Mr A] in 2010 of a
Overall, the care was patchy. I think there was a reasonable
approach to the assessment and decision-making in respect of [Mr
A], and there seems to have been reasonable oversight of the
various staff involved in decision-making and good coordination
between them, but with some significant exceptions.
There are some aspects of the overall systems of care which
appear to have been deficient and which contribute to the overall
approach being not of a reasonable standard.
I shall discuss the various contacts over the course of 2010 to
expand upon my overall conclusion in respect of the standard of
On 23 [Month1] [Ms B] attended the community mental health
service concerned about the behaviour of [Mr A], who was identified
as her flat mate. [Ms B] was concerned that [Mr A] was unwell. The
records of that contact reflect that he would not talk to her and
that he was spending most of the day sleeping. The records show
very little exploration of other symptoms. Some background to the
concerns is noted along with the advice given, that [Ms B] see [Mr
A's] GP and possibly that the Mental Health Act be considered. No
further contact with the Mental Health Service was planned. The
file note of this contact appears to be only a single page of
handwritten text in the body of the clinical notes and 11 lines of typed
I can find no evidence of discussion or of any other
communication with the GP about this contact.
Ordinarily it is useful to ensure that general practitioners are
informed of contacts their patients make with specialist health
services. Although in this situation it was not [Mr A] himself who
made contact with the mental health service, the advice offered
included the possibility of further contact with the GP.
The Health and Disability Commissioner Code of Health and
Disability Services Consumers' Rights confirms that every consumer
has the right to co-operation among providers to ensure quality and
continuity of services. In accord with this and optimal clinical
practice it may have been helpful to alert the GP in some manner to
this contact in order that he had some background should [Mr A]
present to the practice, to assist with that continuity of care. In
my view this would be especially important when such an important
consideration as use of the Mental Health (Compulsory Assessment
and Treatment) Act was being discussed as a possibility.
In my view the omission of contact with the GP in this
circumstance would be viewed with moderate disapproval. It is not
evident however that [Mr A] had contact with the GP before he was
seen again by the mental health service, so this omission on this
occasion seems unlikely to have had any material effect.
[Mr A] was subsequently seen on 22 [Month2] by PACT staff when
he presented to the Emergency Department following [a suicide
attempt]. There is evidence of attention to recent stresses, to
recent symptoms and to matters of ongoing risk. There is no record
of an examination of mental state, although the record notes that
[Mr A] was only partially cooperative with the assessment and it
appears that the examination may have been limited by [Mr A]
terminating the assessment. Ongoing assessment was planned and
arrangements were made for respite care.
It is not clear whether the contact in [Month1] was known by the
PACT staff subsequently involved on 22 [Month2], nor to what degree
the details of prior contact over the period from 2007 to 2009 was
known. I understand though, from the further information provided
by BoPDHB, that the records would have been available to PACT
Whether or not these records were accessed is not clear to me
but the plans that were made appear reasonable given the nature of
the information gathered at the time of this contact.
There was a discussion of the assessment and presentation in the
team meeting on 23 [Month2]. The proposed approach was that he be
offered an appointment with [Dr I], but that if this were declined
he would "be let go on his way".
PACT staff subsequently reviewed [Mr A] at the respite facility.
He agreed to see [Dr I] and the stay at the respite facility was
[Mr A] was again seen on 24 [Month2] by PACT staff. On this
occasion when the forthcoming appointment with [Dr I] was discussed
[Mr A] became angry and somewhat threatening in nature and
terminated the conversation.
The following day a phone call was made to the respite facility
by PACT staff. No concerns were noted.
[Mr A] was visited again the following day at the respite
facility. He confirmed his agreement to see [Dr I] later that day
and declined the offer of help with transport. Staff of the respite
facility noted that they had seen no evidence of acute mental
These plans, to provide respite support and to have further
contact with [Mr A] to review his presentation, were reasonable in
Despite the plan outlined on 22 [Month2] to "reassess mental
state tomorrow" there is no clear evidence in the records of these
further contacts at the respite facility of further attempts to
obtain a detailed history or to undertake a mental state
examination. The notes of contact with [Mr A] over the next few
days reveal only cursory attention to his mental state,
predominantly focused on whether there was suicidal ideation. It
was arranged however that medical review take place.
In such circumstances where assessment has been limited because
of the willingness of a patient to engage in the assessment, or for
some other reason, it is important (as noted by the PACT staff) to
try to continue the assessment, with appropriate arrangements in
place to help address safety and which may facilitate access to
more urgent assistance if required. For [Mr A] therefore the
respite arrangements were appropriate. It would have been optimal
practice for the visiting staff to attempt to explore further
features that might indicate mental disorder, through systematic
enquiry in respect of symptoms and through detailed observations of
a comprehensive mental state examination. However, arranging a
review by a specialist psychiatrist within a few days is
reasonable, particularly in circumstances where there is no
immediate concern and it is not evident that more acute treatment
A phone conversation is also recorded in the notes on 26
[Month2], apparently taking place at around the same time that
staff were visiting [Mr A] at the respite facility. The records of
this call reflect that [Mr A's] 'ex-partner' had locked his
belongings in her garage. The records suggest that she was not
expecting [Mr A] to return to live with her.
A further phone call is documented an hour later, again from the
ex-partner. She reported that [Mr A] had just been to her house and
left stating that he was going to kill himself. Advice was given to
call the police. This was appropriate in these circumstances.
Although on each of these three days the records suggest that
different PACT staff saw [Mr A], the records appear to indicate
that there was an understanding of the nature of his presenting
problems and the plans that were in place for ongoing assessment.
There seems to have been reasonable continuity of care amongst
those staff and there is some evidence of coordination with the GP
in respect of medication while [Mr A] was at the respite
On 26 [Month2], [Mr A] declined the offer of assistance with
transport to the appointment with [Dr I], but did subsequently
arrive for that assessment.
The review by [Dr I] was an appropriate plan given that he had
previously had contact with [Mr A] and it did seem that psychiatric
review was a prudent measure in the wake of the recent [suicide
attempt] and complaints of mood disturbance.
[Dr I] saw [Mr A] with a member of the PACT staff. [Dr I's]
record of that appointment reveals evidence of his awareness of the
recent contact with PACT and the respite arrangements, as well as
the precipitant for this.
The record outlines what appears to have been a reasonably
thorough assessment. Reasonable consideration was given to the
possibility of a mood or anxiety disorder, but neither was felt to
be acutely present. The main difficulties were thought to be anger
and hostility associated with a personality disorder and an acute
decompensation in the face of social stress.
Overall, through this episode of care, there were reasonable
plans in place to further the assessment and there appears to have
been reasonable coordination and sharing of information between
Proper consideration was given to how to manage what needed to
be ongoing risk of self harm, in the face of [Mr A] apparently
being unable to cooperate with a therapeutic approach.
Consideration was therefore given to whether compulsory assessment
and treatment may be required, which was reasonable in the
An application was made for compulsory assessment and treatment.
This was appropriate in this situation. The use of the Mental
Health (Compulsory Assessment and Treatment) Act did not however
continue beyond the section 9 psychiatric examination. The
examination set up by that section of the Act found that [Mr A] was
not mentally disordered. The clinical report arising from that
examination notes that after being sent to the emergency Department
[Mr A's] mood settled and that he had no current intention to
suicide, although said he would if needs are not met.
The more detailed clinical note completed following the
assessment documents consideration by the assessing doctor of
whether mood disorder or psychosis was present and notes
consideration of further thoughts of harm.
In the circumstances and the apparent absence of clear evidence
of mental illness and immediate risk, and in the face of [Mr A]
being willing to remain engaged with immediate treatment, it was
reasonable for the compulsory process to cease at this point.
I note that a psychiatric registrar conducted the examination
set up by section 9. The Act itself requires that a psychiatrist
complete this assessment, unless there is no psychiatrist
reasonably available. In 2010 however it was not uncommon for
suitably experienced registrars to undertake these assessments and
it has only been in the course of 2011 that the Director of Mental
Health has clarified that this previously established practice is
not satisfactory when a psychiatrist could be available to
undertake the examination.
[Mr A] was reviewed by the psychiatry liaison service while in
the general hospital. Information about [Dr I's] assessment appears
to have been available to the psychiatry liaison service. Although
not seen directly by a psychiatrist during this period, the liaison
psychiatry staff had access to and apparently consulted with [Dr
I]. This was appropriate in these
Once medically stable, [Mr A] was felt not to require ongoing
care from the DHB Mental Health Services and the plans were for
ongoing review by the GP, with counselling to be arranged for
primary care funded counselling.
There does appear to have been some difference in understanding
within the DHB about the plans for further care, at least as far as
I can tell from the records provided to me. The liaison psychiatry
file note dated 28 [Month2] is clear that it was felt that [Mr A]
did not require psychiatric inpatient care, the record stating
"...admission to Mental Health Unit not indicated".
The letter of 28 [Month2] to the GP, [Dr G], completed by the
clinical psychologist from the liaison psychiatry service refers to inpatient
psychiatric admission not being required and only refers to PACT
being available should [Mr A's] level of distress become acute or
risk increase. There is no reference to planned outpatient
What I understand to be the discharge summary of this medical
admission appears however to suggest that
there may have been some arrangement for further psychiatric
outpatient care. How the writer of this summary reached this view
is unclear, as this does not appear to be in accord with the
liaison psychiatry plan.
It seems reasonably clear that through this period of care there
was appropriate transfer of information between the mental health
clinicians and reasonable continuity of how [Mr A's] presentation
was understood. Although it is concerning that the medical
discharge summary suggested that outpatient psychiatric care might
be forthcoming, there was direct written communication between the
liaison service and the GP which made the intentions clear.
The psychologist's letter is a reasonable summary of the
assessment by the liaison service. There is reference to the stress
of the relationship disturbances and the impact this appears to
have had on [Mr A's] presentation.
[Dr G] referred [Mr A] back to the Mental Health Service by
letter dated 5 [Month3], apparently received by the service on 7
[Month3]. An attempt to engage [Mr A] with a primary care mental
health programme had been unsuccessful. There was no clear
indication in the referral of any other change in [Mr A's]
presentation and no reference to [Mr A's] current circumstances.
There is no evidence of the GP reviewing the risk or highlighting
any information in respect of risk in the referral to the mental
health service, or any other information that may have highlighted
particular concern. In fact it is not even clear that the GP had
undertaken any assessment himself of [Mr A] or considered the other
advice given in the letter from the liaison service
Apparently however [Mr A] was felt to be too high risk for
primary mental health care programme, on the basis of high scores
on the Kessler scale.
Sensitivity and specificity data analysis supports the K10 as an
appropriate screening instrument to identify likely cases of
anxiety and depression and to monitor treatment outcomes. [Mr A's]
score was 39, consistent with severe anxiety or depression.
Screening tests such as the Kessler do not however replace a
comprehensive assessment. There is no indication in the referral
that the GP reviewed the history and symptoms of concern, or
himself undertook any examination of [Mr A's] mental state.
In repeated reviews, by [Dr I], [Dr K] and by [Dr L],
consideration had been given to the presence of features of anxiety
or depression and these were not felt to be significant to the
point of needing specialist psychiatric care.
The advice that had been given to the GP, to arrange
psychological therapy through the primary mental health care
services does seem to have been appropriate in these circumstances.
Similarly, attention to relationship factors was appropriate, as
there does appear to have been a clear connection between stress in
the relationship and [Mr A's] risk of harm.
This referral to the DHB Mental Health Service was declined by
letter to the GP, dated 11 [Month3]. The letter simply states that
criteria for entry to the mental health service were not met,
although gave some suggestions of other options that might be
The summary of the investigation by the DHB outlines the full
reason for the community mental health team declining this
referral. The reason as outlined in that summary is that there had
recently been comprehensive assessment of [Mr A] and that the
conclusions had been congruent with earlier assessments, that [Mr
A] did not have a major mood disorder or psychotic illness. There
was also apparently some consideration of [Mr A] having been
reluctant to engage in treatment.
All of this is reasonable. There had been several recent
assessments and there had been consideration of the presence of
mood or anxiety disorder. There was no evidence from the GP of his
own clinical findings suggesting a change in [Mr A's] condition.
However, optimum practice of the community mental health team at
this time would have included direct discussion with the general
practitioner in respect of these reasons for the referral being
declined, with that discussion also serving as an opportunity for
the GP to provide further information that might assist
consideration of the referral. Similarly the GP, if seriously
concerned that it appeared the mental health service had not
properly taken into account some aspects of [Mr A's] presentation,
could reasonably have telephoned the service to discuss his
concerns or at the very least highlighted in the referral
information findings from his own assessment that should be taken
into account by the mental health team.
The incident summary notes that the team that considered this
referral was a different team to that which had previously managed
[Mr A's] care, and that this team would therefore not have been
aware of the prior history of high-risk behaviours.
Information from the DHB however suggests that psychiatric
records are held in a central file room in the community mental
health building and that these are accessible to all mental health
staff. At least in theory therefore information about this prior
history should have been available to the team considering
referral. Information from the DHB also outlines that it is
standard practice to obtain prior records when considering what
action to take in respect of a referral and that this is part of
the responsibilities of the intake coordinator.
This statement in the incident review however does seem to
suggest that there was some deficit in the continuity of
information about [Mr A] and it is difficult to reconcile the
description of what should be standard practice in respect of
gathering information and this statement in the incident
[Mr A] was then referred again to the Mental Health Service by
his GP by letter of 14 [Month3]. This referral once again makes no
reference to the GP's own assessment of [Mr A's] current
presentation. There is no evidence that the GP made telephone
contact with the service to discuss what seems to have been some
frustration with what he termed "pass the parcel".
The referral was apparently received on 18 [Month3] and was
discussed at a referral meeting on 20 [Month3]. [Dr C] also
discussed the referral and [Mr A's] background in a senior medical
officer peer review group. This enabled a contribution to be made
to the approach to be taken to the referral from other doctors who
had some prior involvement in [Mr A's] assessment and management.
This was a very appropriate decision by [Dr C].
In this period it appears to me that there were some deficits in
communication. It appears that the GP was concerned that specialist
services needed to be involved but he gave no information that
would have helped the specialist team understand how [Mr A] was
really unable to be treated effectively in a primary care
The specialist team considering the initial referral, according
to the incident review, appears not to have accessed information
that was available about [Mr A's] prior contact with services. When
re-referred, once again there is no evidence of direct discussion
with the GP to consider whether there was additional information in
respect of the GP's own assessment.
The decision however to offer an appointment was appropriate. In
the face of what was apparently some concern from the GP, it was
appropriate for this to be undertaken in a reasonably prompt
An appointment was arranged for late [Month3] or early
[Month4] for [Mr A] to see [Dr C], the
timing of which appointment seems reasonable in the
In his comments to the HDC, [Dr C] identifies that there was no
clear clinical indication to see [Mr A] urgently. In the absence of
any information from the GP suggesting an urgent need, I agree with
There is an implied suggestion that in the absence of
information about any significant urgency, the 'standard' wait of a
month or more for a non-urgent appointment may have been
reasonable. That may be so, but I would generally only accept that
as reasonable if there was a high level of communication with the
GP to ascertain the true clinical picture and with clear advice
about how to manage any concern during the waiting period.
When the appointment did take place [Dr C] appears to have taken
some care to try to engage with [Mr A]. As a result however the
assessment was incomplete because of the constraints of time.
Appropriately, [Dr C] made plans to see [Mr A] again following his
return from leave. [Mr A] was to contact the service should he wish
to have more urgent attention.
[Dr C] notes that [Mr A] had previously engaged with the crisis
team a few weeks earlier. This view appears to have underpinned the
hope that should things change, [Mr A] would make contact with the
My understanding of that earlier contact however is that it
followed [Mr A] presenting after having [attempted suicide] and his
being somewhat reluctant to cooperate with the assessment when he
was first seen. Records of that contact suggest that he was
sarcastic and "projecting aspersions" about mental health services
and their lack of ability to address any of his issues, commenting
that being under the mental health service had caused most of his
Later, his dislike of mental health services is repeated in
records of 26 [Month2]. There is no evidence that on 26 [Month2]
when he was making threats to his partner to harm himself that he
had any motivation to contact crisis staff because of his
In these circumstances I think I was optimistic for [Dr C] to
believe that [Mr A] might proactively contact the mental health
service should he be feeling distressed. This seems to me to be
particularly unlikely if there was not someone within the service
with whom he had a regular relationship.
I accept the points [Dr C] makes in his response to the HDC.
There were some indications that in some circumstances [Mr A] was
willing to have contact, and there was evidence that this had
happened when in an ongoing psychotherapeutic relationship in a
prior episode of care. Having just taken some effort to try to
engage with [Mr A], [Dr C] would have developed some sense of
whether a therapeutic alliance might be beginning to form between
himself, [Mr D] and [Mr A], which might facilitate him proactively
making contact if distressed.
[Dr C] did consider risk in this assessment. He reached a view
that there was no immediate concern and outlines to the HDC how he
reached this view. He comments that
static risk factors were unchanged and that there were no new
dynamic suicidal risk factors identified or reported. "On that
basis the only conclusion I could make about his suicidal risk was
low". He notes "He had a low risk of deliberate self harm but a
high chronic risk of aggression and violence towards others".
This was a reasonable assessment of risk.
[Dr C], in his comments to the HDC, outlines his understanding
of risk as a dynamic concept. He notes that at the time of the
assessment there were no new acute modifiable risk factors. I
agree, as far as I can tell from the records of that assessment. As
before, it appears the most significant dynamic factor contributing
to risk was the quality of his relationship with his partner, with
the associated factors related to his housing.
The outcome of this assessment was apparently that [Mr D] would
be involved in some way should [Mr A] make contact with the
service, pending further assessment when [Dr C] returned from
I think it would have been good practice for there to be planned
interim contact between [Mr D] and [Mr A] to maintain a budding
alliance. Given the quality of the relationship with his partner
also being such a significant element of vulnerability for [Mr A],
interim contact to assess and if necessary attempt to address such
vulnerability would have been an additional safety measure.
I accept that otherwise there was no clear indication for
I understand that there was no entry made in the information
system indicating that the assessment had taken place.
[Dr C] made handwritten notes of this assessment. These notes
are hard to decipher. I understand from the incident report summary
that their significance may not have been clear to other staff when
[Mr A's] partner presented again, if they were in fact
I cannot make out any clear conclusions in those notes and
although the second point of what appears to be follow-up
arrangements identifies an intention for follow-up in one month, I
cannot determine what the first point means.
In my view these records were not of a reasonable standard. The
DHB has provided information in respect of standards of clinical
records. These include each entry being factual, consistent,
accurate, legible, and complete and compliant with generally
accepted standards for the profession. Implicit in this is that
records must also inform further contact and outline the basis of
conclusions with respect to the assessment and treatment plans.
These handwritten records fall short of this standard. I accept
that 'working notes' may sometimes be made and that these serve the
function of an outline that informs or supplements a more concise
summary. Such summary was not completed in a timely manner however
and thus was not available to inform care, and in my view the
handwritten records, even if they had been visible to other staff,
were insufficiently clear to be meaningful.
In my view peers would view this with at least moderate
There is a discrepancy between various people with respect to
whether a case manager was assigned to [Mr A].
[Dr C] in his comments to the HDC reports that [Mr D] agreed to
act as case manager prior to the assessment. The serious
investigation report identifies that on 18 [Month4] PACT became
aware that [Mr A] had a case manager.
According to the incident review summary, PACT staff who had
contact with [Ms B] on 15 and 17 [Month4] did not know that there
was a case manager assigned to [Mr A]. PACT only became aware of
this on 18 [Month4] following their contact with [Mr A's]
ex-partner being discussed at a team meeting.
There is no reference in those last records to that role being
in place, and only on the second of these occasions was information
to be passed on to the community mental health team.
[Mr D] however is clear that he was not taking on a case
It seems to me that through this period the only people who knew
that [Mr D] was to be the point of contact were [Mr D], [Dr C] and
[Mr A]. There was no clear record of this available anywhere.
Whether or not [Mr D] was taking a case-management role is perhaps
even not the most significant issue to consider, as if the
intention was for [Mr D] to be the point of contact, this should
have been readily evident in the records and information
There are clear responsibilities for a case manager. The job
description for registered nurse within the mental health and
addiction services contains a section describing the role. This
notes that the designated case manager for a service user is the
primary person for contact in treatment planning and coordination
of care for that person. The role includes facilitating
coordination and access to care and ensuring smooth transitions
along the care pathway for service users and their families,
resolution of distress and effective management of mental health
issues, and re-integration with family and primary care
Entering information on the patient's clinical record and
notifying other providers is described as being a case manager
These functions seem to be in accord with the role that [Mr D]
was expected to undertake over the month or so after the
assessment. The referral had been accepted. More contact was
planned. No one else was expected to have any role in that period
and [Dr C] was away and unavailable. The expectation that [Mr D]
would be the point of contact, and therefore have the consequential
responsibility for making further arrangements as needed at the
time of contact, is congruent with the description of the case
management role. It is possible to see why [Mr D] is variously
described as being the case manager.
There are some aspects of the coordination of care that were not
of a reasonable standard at this time. It should have been clear
that an assessment had been undertaken by [Dr C] and that there
were agreed outcomes. It should have been clear that [Mr D] was to
be the point of contact. These details should have been available
when [Ms B] made contact
There is evidence these PACT staff knew that the circumstances
at that time resembled prior occasions at which [Mr A] was at
increased risk of harm, but there is no information available that
suggests [Mr D] was advised of these circumstances, or that he
should specifically be informed.
I am not sure of the meaning of the comments in the analysis of
this aspect of care as outlined in the incident review. The review
notes that the significance of the handwritten notes and lack of
information system entry was that when [Mr A's] ex-partner
presented to PACT with her concerns these staff did not immediately
know that [Mr A] had been accepted back into the service and had a
case manager. The investigation team is reported to have considered
this issue and concluded that while this information might have
been of interest to the staff it would not have changed the
[Mr A's] ex-partner was seeking practical information about how
about how she could move [Mr A] from her home. Information was
provided. However, what appears to have been missing is
consideration of the implications of this for [Mr A] given his
vulnerability at times of relationship stress. Such vulnerability
should have been evident from the prior notes.
In my view, this would have been an appropriate prompt for
action of some sort, whether directly by PACT or through PACT
referring the concern to a case manager or identified contact
person, for further review of the impact of these events on [Mr
A's] previously recognized vulnerability to self-harm.
In my view, it would have been appropriate for the service to
make contact with [Mr A] directly.
In summary therefore, a number of things were carried out well.
The arrangements for respite in [Month2] were reasonable and the
psychiatric review was appropriately arranged. When in the general
hospital, there was a reasonable level of psychiatric contact with
appropriate arrangements in place for psychiatrist oversight of
these contacts. Following the second referral from the GP, timely
appointment was arranged. All assessments seem to have been of a
Some aspects of care, whilst perhaps not optimal, could have
been improved. This particularly was in respect to the lack of
direct discussion between the GP and the service, on at least the
occasion of the second referral.
Of more concern is the omission of communication with the GP in
[Month1], and some other aspects of care which would be viewed with
mild disapproval, in my view. These include the failure of staff in
[Month2] to further the assessment of [Mr A] while he was in the
respite facility, despite though the plan was to do so, even though
the review by a psychiatrist was planned. The misunderstanding
between the medical team and psychiatry liaison service, as
apparently evident in the medical summary recording that outpatient
psychiatric review was planned, is also of some concern.
I am most concerned however about what appear to have been
failures in coordination between [Mr D], [Dr C] and the PACT staff
in [Month4], when the role of [Mr D] seems to have been
misunderstood; where there seems to have been incomplete accessing
of records of prior contact; and where factors resembling prior
episodes of [Mr A's] increased vulnerability to self-harm were
identified but not responded to. These would be viewed, in my
opinion, with at least moderate disapproval by peers.
Comment on [Mr D]
[Mr D] is clear that he was not assigned as case manager. He saw
his role solely to be that of a point of contact for [Mr A]. That
may be technically correct, in so far as the standard systems of
allocation of case manager were operated within the service.
I think however that to take this position reflects an
inappropriately narrow approach to the role of a registered
Amongst domains of practice of the registered nurse, as set out
in the description of that role, is the key task of clinical
practice. Amongst the key performance measures within this key task
area are included: undertaking a timely comprehensive and accurate
nursing assessment; engaging in robust ongoing assessment and
management of risk; developing individual treatment plans; and
making nursing judgments.
[Mr D's] comments suggest that he was a passive observer in the
assessment undertaken by [Dr C]. Although I have no detailed
information from the DHB in respect of the purpose of having a
second health professional perspective present at such assessments,
I think it is unlikely the intention is simply to be completely
passive participant. As a registered nurse, [Mr D] has had training
in nursing assessment, including making observations and drawing
conclusions from them. He has a professional responsibility to
apply those skills, to supplement the observations of other
[Mr D's] role description includes "engaging in robust ongoing
assessment and management of risk". I do not interpret this as
meaning passively awaiting someone, about whom there might be
reasonable concern in respect of risk in particular circumstances,
to make contact with the service when such circumstances were seen
to apply. The reference to "robust and ongoing" in my view clearly
sets an expectation of proactivity that was not evident in the way
[Mr D] applied his role.
[Mr D] does of course operate in the context of a broader
clinical team. This should serve as a safety net, with the
processes of collective decision-making protecting individual
clinicians from significant omissions of appropriate responses. A
well-functioning team process, which recognized the vulnerability
of [Mr A] in such circumstances, could have prompted action by [Mr
D], even if he himself had not spontaneously recognized the
importance of doing something. Despite what the DHB advises in
respect of team practice and systems of supervision, this does not
seem to have occurred.
[Mr D] in his comments to the HDC appears to have reflected upon
changes in nursing practice that may be useful. He notes that it is
important to highlight to the team when the period of assessment is
continuing and when a person is acting as point of contact only
prior to a case manager being allocated. This may be an issue that
will be taken into account in the work being undertaken by the DHB
(see further below).
[Mr D] notes that it may have been of benefit for [Dr C] or him
to document on the clinical file that the process had not yet been
completed and what arrangement had been made to complete it. I
agree, although it does seem remarkable that this might not be
[Mr D] notes that he feels it is important to highlight when the
process of case management is able to start. He reports it leaves a
staff member in a precarious position if they are considered to be
managing patients' care and have not had the opportunity to discuss
the assessment, review and update risk management plan and agree a
treatment plan. He feels it is in the best interest of the patient
to have an assessment before allocating the most suitable and
appropriate case manager.
In large part, I agree with these comments. What seems to be
missing however is the element of individual initiative and
responsibility to ensure that they have appropriate support and
supervision in respect of any person with whom they are involved in
care, and that the role they are taking is clear to others, no
matter what the role.
Comment on [Dr C]
[Dr C] appears to have undertaken a reasonable assessment,
within the constraints of trying to establish a relationship with
[Mr A]. His view, that further planned contact to continue the
assessment could wait until he returned from leave, was also
reasonable. What did fall below standard however was the record of
the assessment that was available to inform further care, should
such care be needed before that further planned contact.
[Dr C] says the only change he has made to this practice is to
dictate a brief synopsis of the assessment for the GP as a brief
record with the statement that a comprehensive report will
This is a very appropriate action to take.
He notes also that if there is a specific role for the case
manager this is always discussed with a patient and included in a
written record in the action plan. I am not clear whether this
discussion would encompass what action should be taken should
urgent assistance be needed, if there is no case manager assigned.
It would be appropriate to ensure that this is discussed and
understood, and that the scope of this discussion includes
identifying circumstances in which vulnerability might be increased
and what action to take.
Other aspects of the care, systems or decision-making
processes involved in this case which warrant additional comment or
recommendations for improvement
Overall I think there was too much reliance upon written
communication between the GP and the Mental Health Service. The
referral information from the GP was poor, containing inadequate
evidence of the GPs own assessment and conclusions, but no effort
appears to have been made by either the GP or the service to
contact the other party to clarify concerns and/or decision-making.
I think the standard of the GP referral(s) would be viewed with at
least mild disapproval, as would the failure by both parties to
discuss these concerns directly.
It does appear that there were some deficits also in the process
of discharge from the general hospital in [Month2] 2010.
The DHB has provided a copy of the protocol for discharge from
Mental Health and Addiction Services. The version supplied has an
issue date of [Month5] 2010. I am not clear whether this was a new
protocol or whether this replaces an earlier version. Nonetheless,
the protocol contains some elements that are in accord with what
would generally have been good practice in respect of involvement
of family in the planning process. The document refers to the
discharge plan managing risks associated with discharge "…including
expressed concerns of the family/whanau…" and notes "….arrangements
are satisfactory to….family/whanau…"
As far as I can tell, there was no discussion with [Ms B] about
[Mr A's] discharge.
The DHB notes that [Mr A] was not a
psychiatric inpatient during the period of hospital care in
[Month2]. The comment adds that discharge was discussed with [Mr A]
and that he was agreeable. Reference is also made to the record
that the events leading to admission "took place in the context of
relationship issues which appears to have been resolved since".
There is no record of discussion with [Ms B] in respect of her
view of the relationship and whether these 'issues' had in fact
been resolved. I think this is an important omission, especially in
the presence of the clear understanding, as reflected in this
record, that the relationship issues were a clear stressor.
I think this failure to discuss discharge with [Ms B] in these
circumstances would generally be viewed with moderate
I am not sure whether the DHB, in pointing out that this
discharge was from a general hospital facility, is indicating that
this standard does not apply. If that were the case, I would
disagree. I suspect more likely the DHB is responding to the
reference in the HDC question about the process of planning in
respect of psychiatric inpatients.
Changes implemented by the DHB in response to this
The DHB identifies some protocols that are under review. These
include the Referral protocol and the Discharge from MH&AS
It is not possible to comment on any change in respect of these
protocols as they are on hold pending the review of the intake
coordinator function and role.
Review of the intake coordinator role is also described as being
under way, but this has not been completed either.
An education program about assessment and treatment of patients
with serious personality disorders has apparently been implemented
with some dates identified for some educational sessions. This is
aimed at enhancing staff knowledge and expertise relating to
assessment and treatment of personality disorders.
Education may in some circumstances be useful. However, unless
accompanied by ongoing support for practice change and for
implementation of the learning, education has a relatively short
washout period with little enduring benefit.
The DHB notes some work is under way in respect of case
management allocation and the differentiation of this role from
'2nd health professional' participation in assessments.
Without documentation of any change to the process of allocation
of case managers it is not possible to comment usefully on this
matter. I note however that it appears to have been emphasised that
when someone participates as a 2nd health professional this
participation will also be documented by the 2nd person. It does
not appear to me to be particularly productive use of staff time
for the second person to simply repeat information that is recorded
by the principal assessing clinician, so it would be good for this
work to include attention to the particular perspectives each
clinician brings to this activity.
I note that the expectation in respect of this documentation was
communicated at a Nurses Forum. Unless such communication is backed
up by ongoing audit and supervision of practice this somewhat
"soft" approach to practice improvement is likely to have only
Although aspects of these changes are still incomplete, the
general direction being taken by the DHB to address matters related
to the care of [Mr A] seems appropriate. As noted however, it would
be good to ensure that the improvements are backed up by systems to
ensure ongoing implementation of practice change.
M D Patton
 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."
 Medication used to treat the manic
episodes of bipolar disorder - hyperactivity, poor judgment and
 Antidepressant medication also used
in management of obsessive compulsive disorder, social anxiety
disorder, panic disorder and post-traumatic stress disorder.
 Medication used in the management of
 The Bay of Plenty Community Mental
Health Service comprises the CMH outpatient service and PACT. The
service is divided into two teams according to geographically
defined coverage. Each team includes dedicated acute/crisis
response (PACT) staff, one of whom has the triage role for all new
referrals to CMH. During business hours (0800-1600) Monday to
Friday, outpatient assessment, treatment and review occurs by the
CMH medical team, consisting of one registrar and three senior
 A mild form of bipolar (manic
depressive) illness with less severe mood swings.
 Ms B confirmed to HDC that she
considers Mr A to have been her partner from this time until Mr A's
death. Throughout the times of her moving out and requesting him to
leave the house, she thought of him as her partner, but he was too
unwell and "scary" to live with.
 PACT is a DHB-run community crisis
team which sees new referrals triaged as requiring an urgent or
acute response, as well as existing CMH patients who are exhibiting
early warning signs or are acutely unwell (in collaboration with
existing care providers). PACT staff are available 24 hours a day.
Their job involves assessment of risk and urgency; the development
of clear management plans to minimise risk; communication and
documentation of all assessments and actions carried out as part of
the crisis resolution function; consultation, liaison and
educational activities via contact with referrers, patients and
family members at any stage in the treatment process.
 The multidisciplinary team meeting
occurs each business day morning and is attended by the full CMH
sector team including psychiatrists. There is a smaller version of
the same which occurs at weekends.
 C-L Provides a mental health
service for patients of the General Hospital and ED during normal
business hours (0800 - 1630 Mon-Fri). Referrals are received from
general wards and other mental health specialty services. Care of
patients who are under the care of a CMH team and who are then
admitted to the General Hospital are the primary responsibility of
the C-L team. On discharge from the General Hospital, patients will
be discharged from the C-L service too. If ongoing mental health
follow-up is required, C-L will make a referral to the appropriate
agency ie. GP, PHO services, CMH or other specialty mental health
 This is the psychiatric assessment
examination by a medical practitioner, provided for in the Mental
Health (Compulsory Assessment and Treatment) Act 1992, to determine
whether the proposed patient is mentally disordered within the
definition of the Act, and if so, whether further assessment and
treatment may be required.
 Note on discharge processes:
Protocol MHAS.A1.31 of the BoPDHB provides that all service users
who receive mental health services must have a discharge plan that
is developed collaboratively with the patient and
family/whānau/caregivers (where the patient's consent is given),
that identifies and manages risks associated with the discharge,
including expressed concerns of the family/whānau. Evidence of
review must be documented in the clinical notes. Arrangements must
be satisfactory to the patient, their family/whānau and to the
other providers prior to their discharge.
 The Kessler Psychological Distress
Scale (K10) was developed in 1992 by Kessler for use in population
surveys. Research has revealed a strong association between high
scores on the K10 and diagnosis of anxiety and affective disorders.
There is a lesser but significant association between the K10 and
other mental disorder categories and with the presence of any
current mental disorder. Mr A's score of 39 was consistent with
severe anxiety or depression.
 The triage intake co-ordinator
(one per CMH sector team) processes all new referrals and
categorises them according to required priority of assessment: 1.
Urgent - passed to PACT immediately for contact within 4 hours; 2.
Acute - contact within 24 hours by PACT or designated case manager
(if in working hrs); 3. Non-acute - taken to MDT meeting for
discussion and review within 1 week of receipt. At the MDT, a case
manager is allocated, contact and assessment timeframes established
and appointments booked. It is standard practice to obtain prior
records when considering GP referrals and this is the
responsibility of the intake coordinator. If a referral is not
comprehensive, BoPDHB policy dictates that the intake co-ordinator
"will contact the referrer and/or client, and using the triage
form, gain further information to clarify appropriateness of the
referral and assign priority if indicated". In the case of
referrals triaged as not meeting criteria for the mental health
service, the intake co-ordinator is responsible for writing to the
referrer and providing advice about alternative pathways for
service if appropriate.
 An acute psychological response to
an identifiable recent stressor that causes significant emotional
or behavioural symptoms, lasting less than six months, that do not
meet the criteria for anxiety disorder, post traumatic stress
disorder, or acute stress disorder.
 BoPDHB has confirmed that the 16
Month4 visit was incorrectly dated in the clinical notes as 15
 During working hours there is no
dedicated medical officer available to PACT. PACT is reliant on the
sector psychiatrists to juggle their sector work in order to
respond to acute PACT requests.
 Right 4(2)
 Right 4(5)
 Criteria 7.2.
 Phone communication with HDC
expert psychiatric nursing advisor, Bernadette Paus, 18 January
 Dr Patton's preliminary advice to
the Commissioner, dated 2 May 2011.
 See Opinions 07HDC06607 and
 Page 147 of the bundle of
 From BoPDHB response to
notification, at page 787 of bundle of documents.
 Page 239 of the bundle of
 Page 183 of the bundle of
 The Kessler Psychological Distress
Scale (K10) is a scale developed in 1992 by Kessler for use in
population surveys. Research has revealed a strong association
between high scores on the K10 and a current CIDI diagnosis of
anxiety and affective disorders. There is a lesser but significant
association between the K10 and other mental disorder categories
and with the presence of any current mental disorder.
 I am a little unclear of the date
this assessment actually took place. The incident review report
identifies this taking place on 28 [Month3]. At page 3 of his
response to the HDC, Dr C identifies that he "decided to review Mr
A prior to my planned annual leave... on 4 [Month4]", and later (at
page 7 of this document) comments "including my assessment on 4th
 At page 539 of the bundle of
 In response to the HDC request for
a description of the discharge planning process for inpatients, at
page 733 of the bundle of documents