Investigation: delayed assessment of suicidal woman

A woman had a history of depression, post-traumatic stress disorder, and significant mental health issues. She had received compulsory treatment under the Mental Health (Compulsory Assessment and Treatment) Act 1992 at the DHB.

The woman’s GP made an urgent referral to the DHB’s Mental Health Service for an assessment, owing to the woman’s depression and suicidality. It was determined that she would be reviewed the following morning but, sadly, she died before any assessment was carried out.


Mental Health Commissioner Kevin Allan was critical that the DHB had seriously inadequate systems and processes in place at the time of the woman’s referral. In particular, there was no formal process for triaging referrals, and e-referrals were managed by administrators without review by a clinician for up to 24 hours. Clinicians were also unable to access patient medical records easily, and they had to manage crisis calls in addition to their usual caseload.

“The DHB is responsible for the services it provides, and must ensure that appropriate systems are in place to support clinicians to carry out their roles,” said Mr Allan. He considered that the inadequate systems and processes “contributed to the poor standard of care provided in this case, with the result that opportunities to assess the woman with the urgency required were missed”.


The Mental Health Commissioner noted that since the events, the DHB had implemented a number of substantial changes, which should improve its service quality.

The Mental Health Commissioner recommended that the DHB update HDC on its newly developed mental health crisis service manual, conduct an audit of the current process for the management of incoming mental health referrals, and provide evidence of caseload reviews carried out for Mental Health Service clinicians and report on the effectiveness of those reviews.

He also recommended that the DHB provide a written apology to the woman’s family.

The full report on case 18HDC00078 is available here.