Director of Proceedings v Bay of Plenty District Health Board [2022] NZHRRT 5 (8 February 2022)
The Director filed proceedings by consent against Bay of Plenty District Health Board (“the defendant”) in the Human Rights Review Tribunal, regarding care it provided to Mr A, a mental health services consumer.
Mr A first had contact with the defendant’s Mental Health and Addiction Services (“MHAS”) in July 2014 after his parents and GP became concerned about his low mood and behaviour. From that time until March 2017 Mr A had frequent contact with the defendant’s MHAS and Community Mental Health Service (“CMHS”), and had one voluntary admission to hospital for inpatient assessment and treatment from 21 to 24 August 2016. Mr A’s clinical notes throughout this time record Mr A as variously suffering with low mood, depression, social anxiety, insomnia, self-harm attempts, and suicidal ideation. Tragically, on 31 March 2017 Mr A was found deceased near his home.
The defendant has acknowledged that this was a tragic case involving a number of failures in its care of Mr A. In particular, when Mr A was admitted to hospital as an inpatient he was not seen by a senior medical officer within 24 hours of admission or at all before being discharged from inpatient care, which was inconsistent with the defendant’s policies and protocols. Mr A’s discharge, which was a day earlier than previously agreed by the multi-disciplinary team (“MDT”), was in circumstances where the relevant decision-making lacked input from appropriate medical professionals. In particular, there was no senior psychiatric input into the discharge process or decision. Mr A’s family were not told on discharge about the MDT’s plan for Mr A to have an appointment with a consultant psychiatrist, Dr D, in September 2016, which likely contributed to the family’s lack of knowledge of the treatment plan and Mr A’s subsequent absence from that scheduled appointment. Dr D then discharged Mr A from his psychiatric care, and into the care of CMHS psychologist Mr G, after the single missed appointment, which reflected poor clinical judgement and was contrary to the defendant’s policy and protocol, which required a minimum of two consecutive missed appointments before discharge from psychiatric care. In addition, Dr D discharged Mr A despite not having had an in-person consultation with Mr A and therefore no opportunity to perform his own assessment of Mr A’s clinical requirements. This decision was also made at a time when the MDT was aware that Mr A was particularly depressed/obsessional. There was no psychiatry review of Mr A between August 2016 and March 2017, and little documented discussion of Mr A’s condition by the MDT in the same timeframe. In March 2017, Mr G declined to schedule an appointment with Mr A owing to a perceived conflict of interest, which contradicted Mr G’s duty to provide coordinated services under the Code of Ethics for psychologists working in Aotearoa/New Zealand. The perceived conflict of interest related to the fact that Mr A had begun seeing Ms J, a private psychologist, in February 2017. Mr A was subsequently discharged to Ms J’s private care on 8 March 2017. There was no discharge plan made and/or shared between Mr A, Mr G, Ms J, Mr A’s GP, or Mr A’s family. This was despite the record of contact between CMHS clinicians and Mr A/his family over February and March 2017 showing that Mr A had a high level of risk and service intervention. There were indicators of the need for comprehensive discharge/transfer of care, such as Mr A’s inconsistency in attending appointments, his mother’s high level of concern for Mr A’s safety, and Mr A’s recent discharge from Mr G’s care. Despite these indicators, there was no discharge/transfer of care plan on file, and there was no contact with or by CMHS services documented for the period 8 to 21 March 2017.
The defendant accepts that the care provided to Mr A fell below the standard expected of a healthcare provider in New Zealand. There was a lack of attention to the basic aspects of assessment, monitoring, communication, and clinical decision-making, and inadequate consideration of the level and type of care that Mr A required. This was a collective failure of the system and the people operating in it, for which ultimately the defendant was responsible. The defendant has apologised to Mr A’s family and expressed deep regret over its failings to ensure that Mr A received the support and treatment necessary to maintain his mental wellbeing and prevent his death. Subsequent to these events, the defendant introduced a number of changes to its service. The defendant accepts that it breached Right 4(1) of the Code in that it failed to provide care to Mr A with reasonable care and skill, and Right 4(5) of the Code in that it failed to ensure that there was effective collaboration among providers to ensure quality and continuity of services.
The Tribunal was satisfied that the defendant failed in the care it provided to Mr A, and issued a declaration that the defendant breached Right 4(1) and Right 4(5) of the Code of Health and Disability Services Consumers’ Rights.
The Tribunal’s full decision can be found at: