Lack of intervention and comprehensive management plan for patient who committed suicide

Summary of facts and conclusions

This case involves the tragic suicide of a 37-year-old man, Mr C, at a Mental Health Hospital in City B on 26 May 1999.

Mr C was a former Police Officer who lived in Town C. This report is concerned with the care he received from 1 July 1998, when Mr C first came to the attention of mental health services, until the date of his death.

Over that period Mr C came under the care of District Health Board A in City A, District Health Board B in City B, and District Health Board C in Town C. On 1 July 1998 Mr C was admitted to a Public Hospital in City A. On 13 July he was discharged and was transferred into the care of the Town C community mental health team, under the umbrella of District Health Board C. Mr C remained in Town C until 5 August, when he briefly returned to City A, ended up in Police custody, and again came to the attention of District Health Board A's mental health services. On 11 August, Mr C again returned to Town C, where he remained until 2 December. At that date, following an acute episode, he was admitted to a Mental Health Hospital in City B under the provisions of the Criminal Justice Act. He remained at the Mental Health Hospital until 12 March 1999, at which time he returned to Town C on trial leave from the Hospital. This leave was revoked on 31 March and Mr C returned to the Mental Health Hospital as a compulsory patient where he remained until his death on 26 May 1999.

Mr C's family complained about the services Mr C received from all three regional providers, as well as specifically Dr A from District Health Board A and Dr B from District Health Board B.

A summary of my opinion in respect of the complaint is as follows:

District Health Board B - no further action

I have decided to take no further action in respect of District Health Board B because, in my view, issues surrounding the care it provided to Mr C have been adequately addressed through the independent inquiry and the inquest. I acknowledge that Mr C's family does not accept that these investigations canvassed all the relevant issues. However, District Health Board B has responded proactively to those inquiries in order to improve its services at the Mental Health Hospital, and in the circumstances I do not feel that there is anything further I can add to the process.

District Health Board A - No breach

In my opinion District Health Board A did not breach the Code of Health and Disability Services Consumers' Rights. I consider that District Health Board A appropriately managed the transfer of Mr C from City A to Town C.

Dr A - No breach

In my opinion Dr A provided services with reasonable skill and care and did not breach the Code. While I accept that he may have said the words alleged by Ms C, and that she may have thought he was indicating a reluctance to treat Mr C, I am satisfied that Dr A did make considered decisions in respect of Mr C's care, and was acting appropriately.

Dr B - No breach

Nor did Dr B breach the Code in my opinion. While Dr B was aware that community mental health services in District Health Board C were not highly resourced, it was her view that Mr C's condition was such that a transfer back home was appropriate. Dr B went to reasonable lengths to ensure that Mr C would receive the appropriate follow-up once on trial leave in Town C. In my view she acted with reasonable skill and care.

District Health Board C - Breach

District Health Board C did breach the Code in my opinion. Mr C's family complained that District Health Board C did not provide services with reasonable skill and care, and I obtained independent expert advice from Dr Murray Patton on this issue. Dr Patton made a number of criticisms of the way in which District Health Board C provided services, and concluded that there were gaps in the service which could not be explained by the fact that Mr C lived in Town C, a reasonably remote location in terms of access to services. District Health Board C responded in detail to my provisional report and accordingly I sought further expert advice from Dr Patton. Having taken this further information into account, my opinion remains that District Health Board C breached the Code.

Parties involved

Dr A	Consultant psychiatrist, District Health Board A/ Provider
City A	City in the region of District Health Board A
Dr B	Consultant psychiatrist for Forensic Services, District Health Board B/ Provider
City B	City in the region of District Health Board B
Mr C	Consumer
Ms C	Partner of Mr C
City C	City in the region of District Health Board C
Town C	Town in the region of District Health Board C
Mr D	Mr C's brother
Dr E	Consultant Psychiatrist, District Health Board A
Mr F	Senior Nurse, District Health Board A
Dr G	Psychiatrist, District Health Board C
Mr H	Forensic Mental Health Nurse, District Health Board C
Dr I	Psychiatrist, District Health Board C
Dr J	Psychiatrist, District Health Board B

Complaint

The Commissioner received a complaint regarding the services provided to Mr C by District Health Board A, Dr A (a psychiatrist at District Health Board A), District Health Board B, Dr B (a consultant psychiatrist for Forensic Services at District Health Board B) and District Health Board C. The complaint is that:

District Health Board A

District Health Board A Limited did not provide mental health services of an appropriate standard when treating Mr C. In particular:

• In early July 1998 Mr C was discharged from the secure psychiatric unit at a Public Hospital in City A following a compulsory two week stay under the Mental Health Act and was required to return to City C unescorted despite being advised that an escort nurse would be made available for the journey. In addition, District Health Board A did not formally refer Mr C to the mental health team in Town C.
  
  
• Services that were to be arranged upon transfer from District Health Board A did not occur until Ms C contacted District Health Board C and Town C's mental health teams.

Dr A

When Mr C was under arrest and contained in Police cells in City A on 7 August 1998, Dr A advised Ms C that Mr C was taking his medication and "was not [District Health Board A's] concern".

District Health Board B

District Health Board B did not provide mental health services of an appropriate standard when treating Mr C. In particular:

• On 5 December 1998 upon Mr C's admission into the Mental Health Hospital Ms C tried to make contact with his doctor on numerous occasions but did not receive a response until January 1999 when a doctor contacted her.
  
  
• Most of the contact with District Health Board B was initiated by Mr C's family and the few meetings that did take place occurred after repeated requests from the family.
  
  
• Mr C's family was not consulted about, or involved in, his treatment and discharge plan and was not kept informed during his treatment.
  
  
• Mr C did not receive regular testing of his liver function during his final stay at the Mental Health Hospital as requested by Ms C and his mother.
  
  
• In May 1999 and on the night of his death there were indicators that Mr C would commit suicide but these were not recognised or acted upon. In particular:
  
  
  • On 3 May 1999 Mr C brought a rope into the ward
    
    
  • The documented decline in his mental state, particularly on 25 May 1999
    
    
  • The increased frequency of safety assurances sought by staff
    
    
  • Expressing suicidality on 25 May 1999
    
    
  • Declining to go out with his brother
    
    
  • Not wanting home leave
    
    
  • Refusing telephone contact with Ms C
  
  
  
• On 26 May 1999 District Health Board B did not listen to Ms C when she expressed concern at her partner's behaviour and did not place him on fifteen-minute observations, as requested.

Dr B

On 9 April 1999 Dr B advised Ms C that there was inadequate follow-up care for Mr C in District Health Board C and that District Health Board C was in a "fragile state", but he had been, or was going to be, released from hospital into community mental health care.

District Health Board C

District Health Board C did not provide mental health services of an appropriate standard when treating Mr C. In particular:

• Services that were to be arranged upon his transfer from District Health Board A did not occur until Ms C contacted the District Health Board C and Town C mental health teams.
  
  
• A doctor did not examine Mr C until one month after he returned from District Health Board A and Mr C received only three visits from a nurse between 13 July and 5 August 1998.
  
  
• On approximately 1 October 1998 Ms C asked for further psychotherapy sessions and was not advised of a further appointment until 23 December 1998, with the appointment not being until 20 January 1999.
  
  
• Upon his release from the Mental Health Hospital on 12 March 1999 a psychiatrist did not examine Mr C until 30 March 1999, and this only occurred as the result of repeated requests from Ms C.
  
  
• Mr C's family was not consulted about, or involved in, his treatment and discharge plan and were not kept informed during his treatment.
  
  
• Despite Ms C continuing to advise the Town C mental health team that she was concerned about her partner's condition services were not increased and advice was given that they considered, Mr C to be well.

Investigation process

The complaint was received on 22 June 1999 and an investigation was commenced on 29 June 1999. Information was obtained from Mr C's brother, Ms C, Dr A, Dr B, District Health Board A, District Health Board B, and District Health Board C.

Expert advice was obtained from Dr Murray Patton, an independent psychiatrist advisor, in relation to the adequacy of services provided by District Health Board C to Mr C. During the course of preparing his report, Dr Patton also had discussions with and obtained further material from District Health Board C.

An independent investigation into Mr C's suicide was commissioned by District Health Board B and performed by two staff from District Health Board A, Dr E, consultant psychiatrist, and Mr F, senior nurse. The Commissioner reviewed the findings from this investigation ("the Inquiry"), and a letter from the Inquiry team dated 8 October 1999 clarifying one of their recommendations. The Commissioner also reviewed the report of the Coroner on Mr C's death, and Mr C's medical notes from District Health Board B, District Health Board A and District Health Board C.

Information gathered during investigation

Background

Mr C was a 37-year-old former Police Officer who lived in Town C with his partner, Ms C, and their young son, and had regular contact with his family in City B and City C. He was described by his family as a "widely respected" and "well-rounded" person prior to becoming ill.

Admission to District Health Board A: 1 - 13 July 1998

Mr C first came to the attention of mental health services on 1 July 1998 when he was admitted to the mental health unit at a Public Hospital for compulsory assessment under the Mental Health (Compulsory Assessment and Treatment) Act 1992. On 5 July 1998 Mr C was transferred to a psychiatric ward in another Public Hospital in City A. The District Health Board A discharge summary documented that, at the time of admission, Mr C was seriously mentally unwell with a psychotic illness. According to the discharge summary, his symptoms included paranoid and grandiose delusions focused on a recent high profile murder trial, and possible hallucinations. His diagnosis at this time was thought to be either a schizophrenic illness or bipolar affective disorder. Dr A, a psychiatrist, treated Mr C with sodium valproate, a mood stabiliser, and two anti-psychotic medications.

Mr C's brother stated that on 6 July 1998 the provisional plan was for Mr C to be transferred to the Mental Health Hospital's Secure Unit, City B, with an escort nurse. Dr A advised that by the time of discharge Mr C "was settled", so plans were made for discharge with follow-up by the community mental health team in Town C.

Discharge and transfer of care

District Health Board A advised that "all normal steps were taken in the transfer of care by [District Health Board A] mental health service staff. Staff contacted the Town C mental health team with Mr C's details by telephone, fax and letter."

The District Health Board A clinical notes of 13 July 1998 include an unsigned entry in what appears to be Dr A's handwriting. This entry states " ... change of responsible clinician to [Dr G]. [Town C] has a mental health section and I have spoken to [Mr H, community mental health nurse]." Dr A confirmed that he spoke to Mr H in Town C to arrange follow-up. A fax from District Health Board A on 13 July 1998 documented that Dr G, a psychiatrist in City C, agreed to take over from Dr A as Mr C's responsible clinician.

A preliminary discharge summary from District Health Board A, dated 8 July 1998, initially stated "transfer to [City B] psychiatric services", but this was later crossed out and changed to "discharged to parents in [City C]", and the discharge date of 13 July 1998 recorded. The final discharge summary, dated 22 July 1998, stated "[Mr C] was discharged back to [City C] and he will stay with his parents for at least the short term. He will also be followed up by the CATT [community assessment and treatment] team in [City C]. His responsible clinician will be [Dr G]."

The Discharge Tasks Checklist notes that both Mr C's partner and parents were notified of his final discharge.

On 13 July 1998 Mr C flew to City C via another city. He made the travel arrangements himself after discussion with District Health Board A staff. The clinical record from that day documented "[Mr C] to be escorted to airport 1630h and seen onto plane. Arrangements made for [Mr C's] parents to pick up the other end ... Appropriate documentation faxed to CATT [community assessment and treatment team] [City C] and CMHT [community mental health team] [Town C] ... Discharged from ward 1630h to airport."

District Health Board C Community Care: 13 July - 7 August 1998

District Health Board C confirmed that Mr C's care was formally transferred from District Health Board A to District Health Board C on 13 July 1998.

Mr C's family advised that while Mr C was under the care of District Health Board C, they had serious concerns about "the quality and continuity of services available to [Mr C] in his hometown of [Town C]".

District Health Board C's clinical records documented that the first contact with Mr C was on 14 July 1998 when he was seen at his home by forensic mental health nurse Mr H. Ms C stated that she instigated this contact.

Mr H had phone contact with Mr C on 17 July. Mr H also telephoned Mr C on 23 October and 2 November, but he was not at home, so Mr H spoke to Ms C instead. Mr H saw Mr C in person on 24 July, 30 July and 5 August 1998. Mr C attended an appointment with a District Health Board C psychiatrist on 16 July 1998.

On 22 July 1998 a second District Health Board C psychiatrist assessed Mr C. The clinical notes do not document the reason for the change in psychiatrist. At this time his diagnosis was recorded as bipolar affective disorder "in remission". The psychiatrist saw him again on 5 August 1998, at which time he was "despondent" but "not mood disordered".

Contact with Mr C's family

In response to the complaint that Mr C's family was not consulted about or kept informed about Mr C's treatment, District Health Board C advised:

"[Mr C] was an adult voluntary outpatient of a Community Mental Health Team. He was competent to consent to sharing of information and family support person involvement in his care if he had wished this to occur. He was competent and able to share his own health information with whomever he wished.

[Mr C] was the client and the Community Mental Health staff have no obligation to disclose information or make any insistence that family or a support person are provided information or are involved in his care.

[Mr H] who attended [Mr C] advises [Mr C] did not wish for information to be shared or include family or a support person and this is his right to confidentiality and his right to choose. His wishes with regard to family or support person involvement were respected and this was his choice ... .

[Ms C] was recognised as [Mr C's] support person. ... A support person does not have automatic access to patient information and is not consulted with regard to a patient's care without the patient wishing for this to occur or without them giving consent for this to occur ... [unless] a situation of risk to the client or others was demonstrated ... .

[Mr C's] family would have been involved in his care and outpatient management if he had wished for this to occur. However his privacy and the ability for him to speak to the health professionals openly, without fear of information being shared, was his right. "

Further contact with District Health Board A: 7 August 1998

The family advised that on 5 August 1998 Mr C "disappeared again", and on 7 August 1998 was arrested in Parliament.

Ms C advised me that following Mr C's arrest she rang Dr A at the Police cells. She stated Dr A explained that Mr C would be in care until Monday when he would appear in Court. According to Ms C, Dr A said Mr C was taking his medication and was "quite well" and "not District Health Board A's concern".

District Health Board A could not locate Dr A's notes for the relevant time period. However, they were part of the records supplied by District Health Board C. Dr A's notes from this time stated:

"This man is well known to me as I treated him in [City A] psychiatric unit in June. He has recently been depressed, but is now well, if somewhat elevated in mood and is certainly not depressed or suicidal. In his current state he should not be granted bail but rather be remanded in custody until Monday. On Monday he should be seen by the Forensic Services. ... It may be in his best interest to be transferred to [another Public Hospital in City C] rather than be sent to our local psychiatric unit as he would be near his relatives."

A District Health Board A mental health services contact form dated 7 August 1998 documented that, despite Dr A's advice that Mr C be held in custody until assessed by the forensic mental health team, a lawyer arranged bail for him. The form also documented that Mr C was released from the Police cells on the condition that he return to his home, which he did, having a brief voluntary hospital admission in a town on the way.

District Health Board C Community Care: 11 August - 2 December 1998

Mr C returned to Town C on 11 August 1998 and continued to receive follow-up from Town C mental health services. The second District Health Board C psychiatrist saw Mr C on 19 August 1998. At this time Mr C's working diagnosis was bipolar affective disorder, and his anti-psychotic medication was replaced with lithium, a mood stabilising medication. On 2 September 1998, he was seen again by the second District Health Board C psychiatrist, who documented that Mr C was "objectively not overtly depressed but looks despondent". At this time a blood test showed that his lithium level was sub-therapeutic, and the dose was increased.

Ms C stated that on approximately 1 October 1998 she told Mr H that her partner needed "more treatment than just medication", and asked for Mr C to receive psychotherapy. Ms C stated that District Health Board C referred Mr C for psychotherapy, but there was no appointment available until 20 January 1999. Ms C stated the appointment on 20 January was with a psychiatrist. District Health Board C advised that it does not employ a psychotherapist, but that some of its staff hold psychotherapy qualifications and utilise psychotherapy techniques within therapeutic interventions. District Health Board C stated that "[Ms C's] concerns were acknowledged and recognised as an important part of [Mr C's] assessments. They were considered alongside [Mr C's] presentation and the clinician's assessments, evaluations and plans."

On 16 October 1998 a third District Health Board C psychiatrist saw Mr C. This psychiatrist documented a further episode of depression, and prescribed an antidepressant. A multidisciplinary review of Mr C's case was carried out by District Health Board C mental health services on 2 November 1998. The plan at this time was to retain contact with Mr C on at least a weekly basis, to await psychological assessment and to support and monitor Mr C's prescribed medication. On 27 November 1998, a psychiatrist documented "continued improvement" and stated that Mr C reported "more energy", feeling "more focused" and "enjoy[ing] relationships at work and at home."

Mr C's mental state deteriorated again, and around 1 December 1998 he set off in his car on another impulsive journey, believing it was his mission to achieve justice in relation to the murder trial.

First admission to District Health Board B: 2 December 1998 - 12 March 1999

On 2 December 1998 Mr C was arrested and charged with a number of driving offences committed while intoxicated. Dr B, forensic psychiatrist, advised that Mr C was admitted to a ward in a Mental Health Hospital pursuant to section 121(2)(b)(ii) of the Criminal Justice Act 1985. Dr B reported that Mr C's working diagnosis was schizophrenia, in view of his history of apparent loss of function over seven or eight years, and absence of symptoms of mood disorder.

Ms C stated that upon Mr C's admission to the Mental Health Hospital she tried to make contact with his doctors on numerous occasions but did not receive a response until January 1999 when a psychiatric registrar contacted her. District Health Board B advised:

"We do not have a record of [Ms C] attempting to contact his doctor on numerous occasions, but even if she did not, she should still have been contacted by his doctor early in his admission. We have acknowledged this as an omission on our part to [Ms C]."

In response to the complaint that Mr C's family was not kept informed during his treatment, District Health Board B stated that "[Dr B] and [Mr C's] primary nurse repeatedly made contact with [Ms C] and with other members of the family without this contact being solicited, and some of the meetings that took place were at the initiative of [District Health Board B] staff". District Health Board B's clinical notes documented that between December 1998 and 5 February 1999 there were 24 contacts between Ms C and the staff of the Mental Health Hospital comprising 16 visits and eight phone calls. Ms C stated that she initiated almost all of these contacts. The clinical notes did not document that any of the meetings took place at District Health Board B's instigation. District Health Board B acknowledged that on at least three occasions during this admission the clinical notes did not record any action in response to specific requests by Ms C.

Testing of liver function

Ms C stated that "[Mr C] did not receive regular testing of his liver function during his final stay at the Mental Health Hospital as requested by [Ms C] and his mother". District Health Board B laboratory results show that Mr C's liver functions were checked on 5 February, 12 February and 23 February 1999 with a steady improvement in results (bilirubin level was 70 on 5 February 1999, down to 44 on 23 February 1999). The hospital notes documented that he was also referred to the gastroenterology service for further investigation of the high bilirubin level. At post-mortem his liver and gallbladder were found to be normal.

Discharge planning

District Health Board B records documented that Ms C requested a family meeting shortly after Mr C's admission on 2 December 1998, and that in discussion with Mr C it was agreed to consider this in January 1999. Ms C advised that she first met with Dr B in early March 1999 at a meeting to discuss Mr C's trial discharge. Ms C advised that at this time it was her expectation that Mr C would be seen on a daily basis.

Dr B stated that prior to the trial leave she advised Mr C and Ms C of the difficulties in arranging for Mr C to reliably see a doctor weekly in Town C. Dr B advised that "although [District Health Board C] cannot provide intensive follow-up in centres such as [Town C], every effort was made to ensure adequate follow-up when Mr C was discharged on 12 March 1999". In particular, Dr B advised that she had discussions about Mr C's follow-up with a psychiatrist and psychiatric district nurse in District Health Board C's region and with the Director of Forensic Psychiatry who was based in another city and provided supervision for District Health Board C's community forensic team. She did not state what arrangements were made.

Mr C was released from the Mental Health Hospital on trial leave on 12 March 1999. On 25 March 1999 Dr B wrote to the consultant forensic psychiatrist in City C to emphasise her concern that "this man in particular should continue to be well monitored".

District Health Board C Community Care: 12 - 31 March 1999

Ms C advised that a District Health Board C forensic nurse visited Mr C at home in Town C on 12 March 1999, the day of his discharge from the Mental Health Hospital.

Ms C stated that during the period between 12 and 31 March 1999 she repeatedly advised the Town C mental health team that she was very concerned about Mr C's condition. District Health Board C records documented that Ms C called the mental health team on 22 March 1999, but did not document the content of this telephone call. Ms C stated that despite her concerns, Mr C's services were not increased. Ms C advised that a forensic nurse saw Mr C approximately three times during this period, and a psychiatrist did not examine Mr C until 30 March 1999.

On 30 March 1999 Mr C was assessed by a District Health Board C psychiatrist who documented that "[s]ince he has been back at [Town C] it appears that he has been progressively spiralling down ... He expressed significant negative content, felt hopeless and had little energy or motivation." The psychiatrist also noted that Mr C had once again become preoccupied with thoughts of impulsively travelling to a government building. The psychiatrist recalled Mr C from trial leave, and he was readmitted to the Mental Health Hospital on 31 March 1999 in accordance with his discharge plan.

Second admission to District Health Board B: 31 March - 26 May 1999

Dr B stated that on return to hospital Mr C's working diagnosis was still schizophrenia, and he was treated with increased doses of antipsychotic medication. Antidepressant medication (paroxetine) was added when he developed persistent depression.

Second opinion from a Private Psychiatric Hospital

The clinical notes documented that Dr B discussed the issue of psychotherapy with Mr C on 14 April 1999, and he "accept[ed] that we need to be quite thoughtful about the issues around counselling/psychotherapy".

The clinical record documented that on 9 April 1999 Dr B had a long telephone conversation with Ms C to discuss [Ms C's] concerns about Mr C. As a result of that conversation, Dr B wrote to the Medical Director of a Private Psychiatric Hospital on 19 April 1999 seeking a second opinion on Mr C's diagnosis, and whether psychotherapy would be helpful or contraindicated.

The Private Psychiatric Hospital's psychiatrist's response of 20 May 1999 stated that he thought Mr C's diagnosis was more likely to be bipolar affective disorder than schizophrenia, and recommended some changes in his medication. The Private Psychiatric Hospital's psychiatrist advised that psychotherapy would involve "significant risk" for Mr C. In particular, he commented that if psychotherapy was embarked upon, there would be "some risk of unusual behaviour and a return of psychosis or of suicide". He suggested that Mr C might benefit from residential treatment at the Private Psychiatric Hospital so that he could receive psychotherapy while also undergoing "close monitoring of his state and ongoing treatment of his psychiatric symptoms".

Discussions about community services in District Health Board C

Ms C reported that during the discussion on 9 April 1999 Dr B told her that there was inadequate back-up care for Mr C in District Health Board C and that District Health Board C was in "a fragile state". Dr B advised that by this time "[Dr I] had left [District Health Board C], there had been a reduction in manpower in the community forensic team, and medical cover for forensic services in [District Health Board C] was limited and being given by different doctors". Dr B stated that she did not record the conversation on 9 April 1999, but that she may have used the words "fragile state" to describe services in District Health Board C's region.

Transfer to rehabilitation ward

On 20 April 1999 Mr C was transferred an acute admissions ward with intensive staffing and security, to a rehabilitation ward. The hospital notes documented "[Mr C] returned to the acute admissions ward after weekend leave prior to lunch. He reports his time home went well ... . There is no bed available on the acute admissions ward for [Mr C]. Transferring to rehabilitation ward this afternoon." The rehabilitation ward's nursing notes from the day of transfer documented "Appears positive and hopeful about his future. Nil suicidal ideation evident in conversation. ... [Mr C] has contacted his next of kin and informed of transfer. He verbalised this afternoon that he is feeling slightly uneasy about the change of wards."

Liaison with Ms C and Mr C's family

District Health Board B informed me that Ms C was "extensively consulted and informed regarding treatment and discharge planning" and that family meetings were held to keep the family informed. District Health Board B further advised that "[Mr D], who was the most local member of the family, was encouraged to contact both [Dr B] and nursing staff with concerns if he had them". Dr B stated that between 31 March 1999 and the time of Mr C's death, she "had a number of discussions with [Ms C]", in addition to the family meetings.

The hospital notes documented that Ms C rang the ward on 13, 14, 19 and 26 April 1999 asking Dr B to contact her. From the notes it would appear that her calls were not returned until 27 April 1999 when Dr B contacted Ms C. On 7 May 1999 the notes documented that a nurse rang Ms C at Dr B's request to emphasise that even though Mr C's mood had lifted slightly, he was still at risk of harming himself. According to the notes Ms C responded that she was aware of Mr C's fluctuating mental state and safety risks and was happy to be contacted about his care.

A family meeting was held between Mr C's family and clinical staff on 25 May 1999. Dr B stated that at the family meeting, she explained to Mr C's family that there was likely to be a wait of some months before an inpatient place would be available at the Private Psychiatric Hospital. Dr B stated that she expressed the need to look at various options for providing a safe environment for Mr C during this waiting period, including exploring the possibility of being safely supported in Town C once he had recovered from his depression. Dr B informed me that she had "explored with [City B's] community forensic team whether [they] could try to work jointly with the region's community forensic team to provide adequate cover for [Mr C] in the event of his discharge" but that she had "no intention of discharging [Mr C] at the time of that meeting or within any short time after it". Dr B believed she had communicated to the family that she was only exploring options at that stage and discharge was not imminent.

Indicators of suicide risk

Dr B stated that "[Mr C] had described intermittent thoughts of suicide over a period of years". Mr C's hospital notes indicate that clinical staff at the Mental Health Hospital were aware that he was at risk of committing suicide. For example, on 6 May 1999 Dr B documented in the clinical notes: "continue to carefully and closely monitor mental state as improving mood may fluctuate and may give him more energy and capacity to act out suicidal ideation if it recurs".

The hospital notes documented that during this second admission to the Mental Health Hospital Mr C brought a rope back to the ward from his home after a weekend leave with the intention of using it to hang himself. However, he disclosed this action to Ms C and to hospital staff, and subsequently allowed his belongings to be checked for such items. Dr B informed the Coroner that "in the two weeks prior to his death he had talked of his wish to stay alive, in spite of his level of depression, in order to be a father to his young son of about fifteen months, and his hope that the treatment options being explored would bring relief of his symptoms".

The hospital notes show that as Mr C's depressive illness worsened, the level of observation on the ward increased substantially. Throughout this time he remained on the rehabilitation ward.

On the shift prior to his death he was specifically asked on three occasions about his safety, and he gave assurances that he was "safe" and would not do anything. The notes from this shift documented: "[Mr C] remains low in mood - very withdrawn. Difficulty with engaging in conversation."

Ms C stated that Mr C spoke to her on the telephone on the evening of 26 May 1999 and told her that he had decided not to go out with his brother that night and he "wasn't going to be coming home for the weekend". Ms C stated that she telephoned the hospital and expressed her concerns to a nurse, and asked that Mr C be checked every 15 minutes. When Ms C asked to speak to Mr C she was told that he was sleeping. Nursing notes recorded that he was awake but told staff to tell Ms C that he was sleeping.

The District Health Board B nursing notes documented that Ms C had expressed her concern that Mr C had not gone out with his brother, but the notes did not document that Ms C requested 15-minute observations of Mr C. District Health Board C informed the Coroner that Mr C was observed every 30 minutes as part of the routine observation round, and that earlier in the evening he had had contact with nursing staff more frequently than every 30 minutes. The afternoon shift clinical notes concluded that Mr C "remained safe this shift and close routine observations maintained". District Health Board B informed me that "nursing staff believe they did listen to [Ms C's] concerns about [Mr C's] behaviour and frequently checked with him seeking assurances that he was feeling safe on the ward".

The evening of 26 May 1999

Mr C was last seen alive at 10.45pm on 26 May 1999, when a staff nurse observed him to be in his bed. Nursing handover from afternoon to evening shift occurred at 11.00pm and, according to the Coroner's report, it was "common knowledge to patients on the ward" that staff were occupied for at least 15 minutes during this time. Mr C's room was next checked sometime between 11.15pm and 11.25pm. Mr C was not in his bed, and his body was found on the floor.

Mr C was certified dead at 12.15am on 27 May 1999. On the morning of 27 May 1999 the family was notified of Mr C's death.

The Inquiry

On 28 May 1999 District Health Board B commissioned Dr E, psychiatrist, and Mr F, nurse consultant, both of whom worked for District Health Board A, to undertake an independent inquiry into Mr C's death. The Inquiry concluded that:

"[Mr C] had been suffering from a major depressive illness with associated high levels of suicidality. This had been noted by staff and individual efforts had been made to monitor his risk. ... The events on the night of his death could not have been predicted and ... it is likely that his suicide could only have been prevented if he had been having one-to-one nursing input.

There are however components of the systems of delivery of care and structures within the mental health service which could benefit from increased focus and we would like to make recommendations accordingly.

1. The most striking aspect of our Inquiry is the unsuitability of [the Rehabiliation] Ward for patients who pose any degree of risk. We would recommend that any patient who poses risk [of suicide or assault], not be treated on this ward.

2. Our recommendation is that training be put into place to facilitate a structured process for the improved functioning of multi-disciplinary team meetings ... .

3. The discipline and skill mix on the ward given its present acuity is inappropriate and insufficient. If it is to continue functioning in its present form, we recommend an increased number of registered nursing staff as a minimum.

4. Review of the admission/transfer procedure to and from the [Rehabilitation] Ward. Criteria for admission and criteria for exclusion need to be considered.

5. That staff on the [Rehabilitation] Ward be given a clearer understanding of where the Ward fits within the wider Mental Health service.

6. That there be a review of levels of observation and the process for review.

7. Risk Management Observation - review of training of assessment of suicidality for all disciplinary members of the multi-disciplinary team.

8. If the Ward is to be redesignated as a rehabilitation ward, admission criteria will need to be adjusted."

The Inquiry also found that "[a]lthough the submission from the family describes inadequate contact with the mental health services, the contact clearly was quite substantial and perhaps greater than would normally be the case".

The Coroner's Inquest

A Coroner's Inquest was completed on 16 June 2000. The Coroner's finding was of suicide, with death being due to asphyxia from hanging. The Coroner made the following comments:

"1. It is clear in my view that the deceased should not have been a patient in the [Rehabilitation] Ward, but should have been returned to the secure Ward. That there was an error in this respect was acknowledged by [Doctor B]. ... In my view the issue then comes down to the circumstances of that final transfer on 20 April 1999 and his continuance as a patient in that ward. ... [T]here is I think clear evidence that he was showing suicidal tendencies and that while a patient in the secure Ward his condition in this respect continued to deteriorate, although he did shortly before his death express a wish to stay alive for the sake of his young son. It was recommended that he be admitted to [a private psychiatric hospital] but on 25 May 1999 he, his parents and partner were advised that there would be a three-month wait for that admission to take place. In the days leading up to his death [Mr C] had been openly talking about suicide and the nursing notes at this time appear to confirm his depressed state.

2. The reason why [Mr C] was retained in the rehabilitation ward and not returned to the secure ward is not quite clear. ... It is clear that nearer the time of his suicide his depressive illness was deteriorating and that the level of his observation whilst on the ward increased substantially to the extent that on the shift prior to his death, he was asked three times about his personal safety. However, he did give staff assurances that he was 'safe' and would not do anything. I am conscious that it is easy to be wise after the event but perhaps his assurances were accepted too readily. Apart from that, however, it seems that the concerns of the nursing staff were either not adequately communicated to the clinicians or if they were they were not given appropriate weight. One can understand [Ms C's] concern which she expressed to me more than once at the inquest hearing - what does he have to do to show that he is at risk? ...

In conclusion I refer to two matters:

First even if [Mr C] had been in a more secure ward (or had been monitored even more closely), there is no guarantee that his suicide would not have taken place. He appears to have taken his own life in a deliberate and determined way.

Second [District Health Board B] is to be commended for the prompt steps it took to commission an independent Inquiry and for the actions it has since taken to give effect to its recommendations."

The family's response

Ms C and Mr C's brother provided me with a copy of their comments about the Inquiry. The family expressed particular concern about the following issues:

• The report did not adequately review the circumstances of the suicide and did not adequately identify factors and issues that may have contributed to the suicide.
  
  
• The report suggested that going the "extra mile" for Mr C led staff to tell Ms C that Mr C was sleeping when he was in fact awake. If the truth had been relayed to Ms C she would have been concerned about Mr C's refusal to talk to her, and would have been more insistent that he receive closer monitoring.
  
  
• It was illogical to conclude that "although he was not receiving ten or five minute formal observations, he was being monitored at a level commensurate with this level of supervision" when there was an apparent gap of 30 to 40 minutes between checks.
  
  
• There were no clear reasons given for the finding that there was some conflict between the treatment being offered by District Health Board B and what was felt to be appropriate by the family. The family thought psychotherapy would be a helpful addition, and not a substitute for medication.
  
  
• The conclusion that "the events on the night of his death could not have been predicted" was not justified in view of the many indicators of risk.
  
  
• The report did not mention difficulties with outpatient care in the region as part of its recommendations.

The family supported the recommendations of the report, and requested that the following recommendation be added:

"The insight of close family/caregivers into the mental state of a patient is just as valuable as the observations of staff. Families are usually in a better position to judge what is out of character and may be more attuned to potential warning signs of patient risk. When a patient is acting out of character and family express concerns regarding this staff should listen to the family's concerns and have regard to these concerns in reviewing patient risk and act promptly on these concerns."

District Health Board B's response to the suicide and subsequent reports

District Health Board B stated that it made several changes to their mental health services based on the recommendations of the Inquiry, and the family's response to the Inquiry. In particular, District Health Board B advised:

• District Health Board B has apologised to Ms C and the family.
  
  
• A mechanism has been put in place to address the need for family involvement. Anonymised feedback from the family will be used in education sessions.
  
  
• The number of registered nurses on the rehabilitation ward has increased by filling vacancies.
  
  
• Senior medical input to the rehabilitation ward has been boosted by the appointment of a half-time consultant psychiatrist.
  
  
• The admission/transfer procedure has been reviewed.
  
  
• The process of redefining the role and function of the rehabilitation ward has commenced.
  
  
• There has been a review of levels of observation.
  
  
• A risk management co-ordinator has been identified for the ward and will be used as a resource person by the other staff in relation to the risk management system.
  
  
• Education on assessing suicidality will be provided as part of the ongoing training programme for nursing staff.
  
  
• Mental health services will be regularly reviewed and audited to ensure compliance with the National Mental Health Standards.

District Health Board B advised:

"We accept that there were indicators of increasing depression and intermittent suicidality from [Mr C], over the weeks preceding his death, although his mental state had fluctuated over this time. [Mr C] did not express suicidality to staff on 26 May 1999 and in fact while describing very low mood and no energy to go out with his brother or to go home as planned the following weekend, repeatedly assured staff that he was not suicidal and had no plan to commit suicide. ... We acknowledge that staff placed reliance on [Mr C's] assurances to them, in the light of his previous openness about such matters, which in the event proved to be unfounded, and that while they were checking on him and talking with him frequently they did not place him on formal observations. We have acknowledged to [Mr C's] brother, [Mr C's] parents and [Ms C], that nursing practice is a matter of judgement and in this case the judgement was erroneous."

Independent advice to Commissioner

Expert advice was obtained from Dr Murray Patton, an independent psychiatrist, in relation to the level and quality of services provided to Mr C by District Health Board C. A full copy of Dr Patton's advice is appended as Appendix I.

Response to Provisional Opinion

District Health Board C provided me with a detailed response to my provisional report on this matter. The response addressed each of the particulars of the complaint against District Health Board C. The response also addressed a number of the factors I relied on in the provisional report in finding a general breach of standards, and in particular the issues surrounding the period of trial leave, the involvement of Mr C's family, and District Health Board C's response to concerns raised by Ms C.

A copy of the response received from District Health Board C is annexed to this report as Appendix II. The following is a summary of the key points in the response:

Period of trial leave

In my provisional report I commented, based on advice from Dr Patton, that planning for contact by District Health Board C mental health staff during Mr C's period of trial leave from the Mental Health Hospital was not consistent with the level of monitoring that had been indicated was required. District Health Board C's response to this was that:

• Dr B remained the responsible clinician throughout that period and was the person ultimately responsible for ensuring that the appropriate psychiatric follow-up was arranged;
  
  
• Dr B's letter to the psychiatrist to whom care was ultimately transferred, Dr I, which stated that "close monitoring" was required, did not reach Dr I until after the decision had been made to cancel the period of trial leave;
  
  
• Contrary to what was asserted in the expert advice, District Health Board C's clinical notes do refer to Ms C's concerns and views relating to Mr C over that period;
  
  
• Staffing shortages at District Health Board C caused difficulty in being able to follow up Mr C when he was in Town C;
  
  
• District Health Board C responded proactively and with flexibility to Mr C's needs while he was on trial leave. Contact was made more frequently than originally planned.

Family involvement

In my provisional report I commented that Mr C's family were not involved in his treatment and progress to the extent desirable, and nor was Mr C encouraged to involve his family.

In response, District Health Board C notes:

• It is the patient's right to make decisions;
  
  
• Mr C had expressed a wish for confidentiality;
  
  
• Mr C was encouraged to involve his family;
  
  
• Further family involvement was prevented by Mr C's decisions.

Response to Ms C's concerns

In my provisional report I noted that District Health Board C displayed an under-responsiveness to concerns raised about Mr C by Ms C. In response, District Health Board C noted:

• With one exception, action was taken in response to Ms C's concerns;
  
  
• Contacts by Ms C were responded to in an appropriately proactive manner.

Actions/Recommendations

In my provisional report, I made a number of recommendations in relation to the ways in which District Health Board C could improve their mental health services, in addition to those measures already implemented since Mr C's death.

District Health Board C responded, noting that a number of my recommendations had already been addressed through measures implemented since Mr C was in their care. However, I shall deal with this issue in more detail later in this report, in the Recommendations section.

Further expert advice

In order to address the issues raised by District Health Board C in response to my provisional report, I sought further expert advice from Dr Murray Patton, psychiatrist. Dr Patton was provided with a copy of my provisional report and District Health Board C's response to that report.

A copy of Dr Patton's further advice is appended to this report as Appendix III.

Code of Health and Disability Services Consumers' Rights

The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:

RIGHT 4

Right to Services of an Appropriate Standard

1) Every consumer has the right to have services provided with reasonable care and skill.

2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

3) Every consumer has the right to have services provided in a manner consistent with his or her needs.

...

5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.

Commissioner's Opinion

Opinion: No further action - District Health Board B

As a result of my investigation I have decided, in accordance with my discretion under section 37(2) of the Health and Disability Commissioner Act 1994, to take no further action in respect of the complaints against District Health Board B.

The care that Mr C received at District Health Board B, and in particular the events surrounding Mr C's death, have been the subject of two reviews, the 'Inquiry' instigated by District Health Board B, and the Coroner's inquiry. While Mr C's family had some residual concerns following the inquiries, in my view District Health Board B carefully considered the concerns highlighted by the inquiries and the family, responded appropriately to the issues raised and the recommendations made, and has taken reasonable steps to improve its mental health services. Any further investigation is unlikely to shed further light on these matters. I note that the Coroner commended District Health Board B on the action it has taken to give effect to the recommendations of the Inquiry. In my view no further benefit will flow from any further action on my part in terms of promoting and protecting consumers' rights.

Opinion: No Breach - District Health Board A

In my opinion District Health Board A did not fail to observe appropriate practices and procedures in relation to the transfer of Mr C back to District Health Board C, and accordingly did not breach the Code. Nor did District Health Board A breach the Code by failing to co-operate with mental health services in District Health Board C's region to ensure continuity of care for Mr C.

District Health Board A advised that "all normal steps were taken in the transfer of care by [District Health Board A] Mental Health Service staff". This is supported by the nursing notes, which show that the appropriate discharge tasks were all performed.

District Health Board A staff contacted mental health services at District Health Board B prior to the transfer. It was agreed that Dr G should take over as responsible clinician. Dr A at District Health Board A also spoke to Mr H, the community mental health nurse in Town C. Mr C's family was contacted and it was arranged that they would meet him at the airport when he arrived.

It appears that Mr C's transfer complied with the relevant practices and procedures in place at District Health Board A, and that these procedures ensured Mr C's effective discharge and transfer to District Health Board C.

Mr C's family was particularly concerned that while an escort had been promised, one was not provided. I note that District Health Board A records stated: "[Mr C] to be escorted to airport 1630h and seen onto plane. Arrangements made for [Mr C's] parents to pick up at other end . ... " Mr C clearly arrived safely in City C and there is no indication that District Health Board A acted inappropriately in relation to this matter.

Mr C's family was also concerned that services that were to be provided on transfer to District Health Board C were not provided quickly enough. In my view, this is not a matter for which District Health Board A could be held responsible, as its staff clearly took reasonable steps to transfer care.

In my opinion, District Health Board A organised Mr C's transfer to District Health Board C in a manner consistent with appropriate policies and procedures, and co-operated fully with District Health Board C's mental health services in an attempt to ensure continuity of care. The documents show that matters such as the transfer of medical care and notification of Mr C's family were carried out by District Health Board A staff, and lines of communication between District Health Board C and City A providers were open and effective.

My opinion is therefore that District Health Board A did not breach the Code.