Lack of assessment and planning in acute mental health unit

This case concerns a man who self-harmed while a patient on a forensic in-patient unit. The district health board was found in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill, due to the lack of clear assessment and planning in relation to the management of the man’s behaviours.

The man had been transferred to the forensic unit from prison where he was displaying agitated and aggressive behaviours. On admission to the unit the man was assessed as being a high risk of harm to himself and others, and initially was managed in seclusion but later was transferred to the main ward. On day four of his admission, the man was provided with a razor which subsequently he used to self-harm.

The Deputy Commissioner considered that there was a lack of clear assessment and planning for the management of the man’s risk and impulsive behaviours and, as a result, it is not clear whether important information about the man’s level of risk was communicated to nursing staff adequately.

The Deputy Commissioner noted that for people who experience acute episodes of distress, relative risk of self-harm changes rapidly and frequently, as occurred in this case. The Deputy Commissioner acknowledged that the district health board had a range of tools to assess and manage risk, but considered there was room for improvement in the way risk is communicated.

The Deputy Commissioner was also critical that razors were available on the unit, and that there was no policy to guide staff regarding access to them.

Following this incident the district health board discontinued use of blade razors.

The Deputy Commissioner made a number of recommendations around the changes the district health board made following this incident to support care planning across its mental health and addiction services, and the district health board’s introduction of risk assessment tools for the assessment and management of its consumers.

The Deputy Commissioner also wrote to the Ministry of Health earlier this year to request support for the development of consistent risk management and safety planning protocols to replace the practice of risk prediction still being used in some services.

28 April 2022