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Standard of inpatient mental health services, Southland District Health Board (01HDC11139)

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(Southland District Health Board, October 2002)

Public hospital ~ Inpatient mental health services ~ Standard of care ~ Co-ordination with family ~ Discharge planning ~ Management responsibility ~ Resource constraints ~ Rights 4(1), 4(2), 4(5)

The Commissioner undertook an own-initiative investigation into the quality of care provided to a mental health patient (Mark Burton) by an inpatient mental health unit (at Southland Hospital). He was admitted as a voluntary patient, suffering from paranoid delusions. The day after being discharged from the unit (seven weeks after admission), he killed his mother.

The medical officer, who was for all practical purposes the patient's psychiatrist (although not trained or vocationally registered as a psychiatrist) was found to have breached Rights 4(1), 4(2) and 4(5) of the Code. He did not provide services of an appropriate standard in relation to documentation, assessment and care planning, clinical risk assessment and management, discharge planning, involvement of family, leave planning and overall management of care. The Medical Practitioners Disciplinary Tribunal subsequently found him guilty of professional misconduct, and he was suspended for six months, required to complete further training before practising psychiatry, and fined.

The senior psychiatrist responsible for oversight of the medical officer's practice failed to adequately monitor and review his standard of care. This was a breach of the standard expected of a clinical director (notwithstanding resource constraints and his heavy workload) and a breach of Right 4(2) of the Code. The psychiatrist was subsequently found not guilty of a disciplinary offence.

The patient services manager and the team leader were found not to have met the standards expected of managers within an inpatient mental health service, in breach of Right 4(2) of the Code.

The care and co-ordination provided by a primary nurse and social worker was found substandard; the arrangements for continuity of care by a mental health needs assessor were criticised; and the documentation of an alcohol and drug counsellor was held to be deficient.

The District Health Board failed to fulfil its organisational duty of care and skill, in breach of Right 4(1) of the Code. Contact and co-ordination with the patient's family was inadequate; the discharge was poorly planned; and there was a lack of co-ordination between the inpatient and community mental health teams. The staff shortages faced by the small geographically isolated District Health Board did not excuse the lack of care.

Human Rights Review Tribunal proceedings against the medical officer and the District Health Board were settled.