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Inadequate psychiatric assessment of patient with head injury (05HDC13239)

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(05HDC13239, 11 September 2007)

Psychiatrist ~ Psychiatric nurse ~ District health board ~ Respite care provider ~ Psychiatric illness with head injury ~ Assessment and treatment ~ Right 4(1)

A 24-year-old man was admitted to a hospital's psychiatric unit for observation after being assessed in the Emergency Department with symptoms of anxiety which had developed while his grandparents were away on holiday.

The following day, a psychiatrist formed the view that the patient was not suffering from a psychiatric illness, but that his judgement was impaired as a result of a head injury he had sustained as a child. The man was placed under the care of community mental health services and transferred to supported accommodation for respite care as a voluntary patient.

The next day, the patient developed inappropriate sexual behaviour. He also wandered from his respite accommodation but was persuaded to return. The community mental health services were notified but were satisfied that the patient was not at risk of harm. The patient was placed under observation.

The following day, the patient left the respite facility again. He deliberately stepped into oncoming traffic and was killed as a result of a collision with a vehicle.

It was held that the psychiatrist failed to provide an appropriately thorough assessment of the man. The decisions made by the psychiatrist in relation to the man's care and treatment were not well considered or properly documented. Although the psychiatrist did plan to consult with the family, this could have occurred prior to the patient's discharge from the ward since his grandmother was due back shortly. No specific information was provided to the mobile nursing team other than the need to monitor the man, or about the importance of consulting with his grandmother to clarify the diagnosis. This omission may have contributed to the lack of reassessment following his transfer to respite care. The psychiatrist was found to have breached Right 4(1).