The Health and Disability Commissioner (HDC) has found the rights of an at-risk disabled child were severely compromised when she was wrongly treated as an adult mental health patient.
In a decision released today, HDC found Health New Zealand breached the Code of Health and Disability Services Consumers’ Rights after the 11-year-old, autistic, Māori child was incorrectly identified as a woman known to mental health services. The child was admitted to an adult mental health inpatient unit, where she was twice restrained and administered psychotropic medication intended for an adult.
HDC found that Health NZ breached: Right 4(1) of the Code for failing to provide services with reasonable care and skill; Right 4(3) for failing to provide services that took account of the child’s needs; and Right 3 for failing to provide services in a manner that respected her dignity. In light of the seriousness of these breaches, the Deputy Commissioner referred Health NZ to the Director of Proceedings to consider whether proceedings should be taken.
Deputy Commissioner Rose Wall said that systemic failings led to serious mistakes occurring.
“This child was among the most at-risk consumers engaging with the health system and the care she received fell seriously short of what she was entitled to. Her dignity was not upheld during her interaction with the health system and the whānau have expressed the ongoing detrimental impact these events have had on the child and whānau, including a significant loss of trust.”
Ms Wall noted it was reasonable to assume the events would not have occurred had the child not been disabled and non-verbal in the circumstances. Alongside considering the seriousness and specific circumstances of this case, Ms Wall said, “this case should be understood within the wider context of a health system which frequently fails to meet the needs of disabled people.”
The need for coordinated, cross-system action to improve the care provided to disabled people has been outlined in HDC’s recently published thematic report on the health experiences of disabled people.
Ms Wall said it was extremely important that changes are made to prevent a similar incident from occurring in the future.
“This decision is not only about accountability for what occurred, but ensuring learning and system improvement to better protect disabled and at-risk consumers in the future.”
“The expert who advised on this case commented that other services would also be vulnerable to a similar error. This calls for Health NZ to take leadership, and ensure all districts have appropriate systems and processes in place for supporting disabled people and other at-risk consumers who engage with the health system.”
The Deputy Commissioner was supportive of the recommendations made by Health NZ in its Rapid Incident Review. She made some additional recommendations around improving the use of augmentative and alternative communication tools, reviewing the use of restraint and providing training to staff on admission procedures.
The Health Experiences of Disabled People report is available on the HDC’s website: https://www.hdc.org.nz/news-resources/news/disabled-people-s-tangata-whaikaha-experiences-of-health-services-report-on-complaints-to-hdc/
HDC’s decision about this case is being released on the same day as an inquiry report by the Director of Mental Health. That report will be available at the Ministry of Health’s website: https://www.health.govt.nz/
Media Contact:
Natasha Davidson
027 432 6709
communications@hdc.org.nz