Co-ordination of discharge from hospital between medical and mental health teams

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

A District Health Board

A Report by the Health and Disability Commissioner

Overview

Mr A had a long history of mental health and medical problems and also suffered from substance abuse. Consequently, he posed many complex challenges for his health care providers.

This report examines the care provided by the District Health Board (the DHB) to Mr A in 2005, over the last seven months of his life. During this period he was a client of the DHB mental health services, and was admitted to hospital on a number of occasions with medical problems. He was admitted suffering from the effects of an overdose of opiates, and he was discharged after only a few hours. He was readmitted three hours later, in the early hours of the following day, still suffering from the overdose, and pneumonia was diagnosed. He remained in hospital until discharge four days later, but did not take his medications (including antibiotics) with him. Mr A was not seen again alive by his family or any health professional, and was found dead a few days later.

Parties Involved

Mr A                                       Complainant/Consumer (dec)

Mrs B                                      Mr A's mother

Dr C                                        Psychiatrist

Dr D                                        Psychiatrist

Dr E                                         Psychiatrist

Dr F                                         Psychiatrist

Mr G                                        Registered nurse

Mr H                                        Clinical nurse specialist

Dr I                                          Consultant physician

A District Health Board          The District Health Board

Complaint and investigation

On 16 May 2007 the Health and Disability Commissioner (HDC) received a complaint from Mrs B about the services provided to her son, Mr A, by a District Health Board (the DHB). The following issue was identified for investigation:

The appropriateness of the care provided to Mr A by the District Health Board over a period of seven months in 2005.

An investigation was commenced on 3 August 2007. Information was obtained from Mrs B, the Coroner, and the DHB. Independent expert advice was obtained from specialist physician Dr Geoffrey Robinson and general and forensic psychiatrist Dr Peter Miller, whose reports are attached as Appendices 1 and 2.

Information gathered during investigation

Background

Mr A started to experience behavioural difficulties during his early adolescence. In November 2002, Mr A (aged 27) was assessed by psychiatrist Dr C following an allegation that he had physically threatened another person. Dr C concluded that Mr A suffered from chronic psychosis and schizophrenia, which was complicated by the use of alcohol, illegal drugs (amphetamines and cannabis), and Addison's disease.[1] Dr C considered that Mr A's offending was closely linked to a relapse of his mental illness. Dr C assessed Mr A as having a number of disorders: anti-social personality disorder, poly-substance abuse and dependence, schizophrenia, Addison's disease, and Hashimoto's disease.[2]

Follow-up mental health care was attempted in the community, and Mr A occasionally had contact with medical and psychiatric services when he was admitted to hospital because of his Addison's disease. Mr A was often homeless.

Hospital admission - 6 January to 21 February 2005

On 6 January 2005, Mr A was compulsorily admitted for inpatient mental health treatment[3] as his mental health had deteriorated. The subsequent discharge summary described Mr A's presenting problems as paranoia, "disorganised thoughts and behaviour", and failing to comply with his prescribed medications. His diagnosis was recorded as a relapse of schizophrenia caused by non-compliance with medication.

During his admission, it was suggested that Mr A have injections of his psychiatric medication, but he and his mother were opposed this.

Psychiatrist Dr D assessed Mr A on 27 January. As stated in his subsequent report for the Family Court, this was "for the purpose of providing a second psychiatric opinion to assist [the Court] in making a Compulsory Treatment Order". Dr D stated in his report:

"I do not believe that [Mr A's] psychiatric symptoms are produced solely by the abuse of illegal drugs or alcohol. I also do not believe that Addison's disease is the only cause of [Mr A's] psychiatric symptoms. …

[Mr A] has limited insight into the impact of his condition on his mental and physical wellbeing. He has had approximately ten admissions to hospital for Addison's disease, usually because of his poor adherence to treatment. He tends to deny his psychiatric symptoms, particularly the hallucinations. He attributes all his psychiatric symptoms to drug abuse. I therefore believe that his insight into his condition and the appropriate management of them is poor and that he is likely to continue to neglect his physical and mental health as a result of this poor insight.

In my opinion [Mr A] requires close monitoring and regular treatment for both his physical and mental conditions as well as his substance abuse. He has previously shown that he is unlikely to adhere to either regular monitoring or regular appropriate treatment without some compulsion to do so. Even with this compulsion, I believe that managing [Mr A] in the community has in the past and could well continue to be, extremely challenging. … In my opinion a compulsory treatment order for [Mr A] will contribute towards him receiving adequate treatment for his psychiatric and physical disorders."

A compulsory treatment order directing change from inpatient to community treatment status was completed on 2 February 2005, and was due to expire on 16 August 2005.

At a discharge planning meeting Mr A was reviewed by psychiatrist Dr E and it was planned that Mr A would be transferred to community care with community treatment status.[4]

Care in community - 21 February to 6 July

Mr A was discharged on 21 February to a boarding house. The DHB advised that Mr A remained in "intermittent contact" with the outpatient team, the section of the DHB mental health service that was responsible for his care.

A home visit was made on 22 February, but Mr A was not at home. A message was left asking him to contact the outpatient team, and he telephoned the next day to advise that he would be going away for four weeks.

On 24 February, Mrs B called to say that her son had told her he was now in another city.

On 2 March, Mr A called the outpatient team to request a further prescription, and advised that he had been taking his medication. He agreed to return for a medical review on 10 March.

As part of the monitoring of his care in the community, a home visit was made on 7 March to Mr A's boarding house. However, the manager advised that Mr A had left and was supposed to have returned the previous week.

On 9 March, Mr A advised that he could not come to the rearranged medical appointment, and that he was having financial problems and might not have enough money for accommodation.

On 10 March, Mrs B contacted the outpatient team to say that her son had stayed with her overnight, and that he was not currently agitated or distressed.

On 16 March, Mr A was assessed by psychiatrist Dr F. Dr F recorded that Mr A "was pleasant enough and [coherent] and happy to continue his medication although he disagreed with the diagnosis of schizophrenia and attributed his paranoid ideas to the use of amphetamines and other illicit [drugs]". A further account of the assessment by Dr F was recorded by a registered nurse:

"[Mr A] denies percusatory delusions. Says he is compliant with medications and told that he will be put on [injections] if re-admitted again. Does not want to go back to [boarding house] and does not require any help with finding accommodation. Stayed with his mother until today and will let [the outpatient team] know of his new address … Not sleeping and requesting [sleeping tablets]. Prescribed 1 month - told of dependency effects."

Mrs B contacted the outpatient team on 31 March as she was concerned that her son had not found accommodation. The record of her call states:

"[Mrs B] seeks confirmation of [Mr A's] attendance at [doctor's] appointment and inquiring over the frequency of [Mr A's] needs to see [doctor]. She expresses her concern that [Mr A] has still not found accommodation which may be due to his mental ill health. He visited her over Easter and he appeared stable. She is adamant that he is taking his medications though he still rejects the rationale for this. Mother is at a loss in what to do to help him. However thinks he needs monitoring as chances of him relapsing is high. She will continue to liaise with the outpatient team."

The next entry in the clinical record is on 24 May, when Mrs B advised the outpatient team that she had not seen much of her son recently. However, she reported that he had been in hospital twice because of his Addison's disease, and had also been arrested by the Police.

On 10 June (the next entry) the outpatient team contacted Mrs B. She advised that her son was living in a "Lodge" in another suburb, and that he was "better".

The DHB stated:

"On the 1^st July 2005 [Mr A] was seen for a Section 76 Mental Health Act assessment and review meeting, and the Psychiatrist and Community Health Nurse found him to have been in a reasonable mental health state. He was denying delusions, but admitting to occasional hallucinations and generally minimising his problems. He was consenting to continue with his medication but did not want help with his addiction problems or with supported accommodation. His mother had reported that in the previous month when she had contact with him his mental health had seemed reasonable."

Admission to hospital - 6 July 2005

In the evening of 6 July, Mr A was reported to be behaving unusually in a shopping centre, and an ambulance was called for him. He was found by the ambulance crew (at 8.21pm) to have considerably reduced levels of consciousness and pinpoint pupils. It was suspected that he had taken an overdose of a narcotic drug, and a specific antidote, naloxone, was administered by the ambulance crew. He was taken to the public hospital's Emergency Department (ED).

On arrival at the hospital at 9pm, Mr A was assessed as drowsy but alert. Clinical observations were performed at 9pm and 9.30pm, the latter including neurological observations that indicated Mr A was fully conscious. Mr A was placed on cardiac monitoring, and his observations were recorded every 15 minutes.[5] No electrocardiogram (ECG) was performed and no tests were performed (urine or blood) to check for the presence of illicit drugs. The DHB advised that it was not standard practice to take toxicology tests as the methadone overdose had been confirmed.

A CT scan was performed because of abrasions on Mr A's head. (He had been found by the ambulance crew banging his head against a wall.) The CT scan showed no abnormalities.

When awake, Mr A advised that he had taken intravenous methadone.

The ED staff contacted registered nurse Mr G of the Liaison Psychiatry department. He recorded that ED medical staff did not find Mr A mentally unwell in relation to his psychiatry review of 1 July. Mr G recorded:

"Once he has fully recovered physically they will discharge him home, probably in the next hour or two. They do not see the need to seek further psychiatric opinion in the ED setting tonight."

By 11pm, Mr A was assessed as alert, "talking sense [and] not acutely psychotic". He stated that he did not want to stay in hospital. Following discussion with the senior consultant on duty, it was decided to discharge Mr A, and to refer him to his GP for follow-up. Mr A was reminded of the need to continue to take his regular medications, and a referral was made to the psychiatric team. He was discharged at 11.20pm.[6] It was recorded by a nurse in the section of the documentation relating to discharge that he lived alone, and was going home by taxi. No details were recorded of GP follow-up or advice given regarding his head injury.

(There is a separate section of the documentation that relates to self-discharge, and this was not completed.)

A discharge letter was completed which described Mr A's care in ED, with the advice that he was discharged, given advice on any symptoms of blood sugar levels, and the need to take his medication and to obtain follow-up with his GP. It adds that the psychiatric nurse was to advise the outpatient team that Mr A was in hospital, but there is no record in the outpatient team notes that such contact was made. It is not noted on the letter to whom it was sent.

The DHB advised that Mr A was told of the risks of leaving the department, "but it is unclear that all risks were discussed". However, the DHB added:

"The problem was poor compliance with advice after discharge, not that [Mr A] was physically unfit for discharge or not competent to make the decision that he did not wish to stay in hospital."

Admission to hospital - 7 July 2005

Mr A represented to ED at 2.55am, having been advised by Police to go back to hospital as his consciousness level had deteriorated. On examination, it was noted that he had pinpoint pupils, and he fell asleep during the assessment. A Naloxone infusion was commenced, together with intravenous (IV) steroids (to treat the Addison's disease) and IV fluids. A further CT scan was performed, the results of which were normal.

Mr A was assessed by Clinical Nurse Specialist Mr H from Liaison Psychiatry. Mr H summarised his report:

"[Mr A] does not present as being acutely mentally unwell, he gives a coherent account of his actions and appears co-operative to the care being offered.

…

To remain in [ED] overnight for more medical observation. For likely discharge Friday morning after further review by our service."

Because of his chest infection, it was decided to admit Mr A to hospital under the care of the physicians. Consultant physician Dr I decided to keep Mr A in hospital over the weekend. Dr I subsequently stated:

"At no stage during [Mr A's] hospital admission was he noted to [have behaved] unusually nor did he express any ideation of suicide, delusions or hallucinations."

Mr H made another visit to assess Mr A on 8 July, but by this time he had been transferred to the ward. Mr H recorded:

"[Mr A] gone from [ED] this morning so I assume he self discharged overnight. [ED] notes not available at this time. I will advise the outpatient team of outcome of [Mr A's] visit here."

An admission to discharge plan was completed on 9 July. This stated that Mr A lived with his mother. The form was blank in the sections that asked whether Mr A had a history of self-harm or harm to others, or would have problems "managing at home after discharge". The nurse ticked the boxes that stated there would be no "major concerns about housing, employment or finances for the patient upon discharge", and no requirement for "additional or ongoing support/education in the community".

Over the weekend, Mr A's condition improved, and his antibiotics were altered to tablets.

On 11 July, Mrs B contacted the outpatient team as she was concerned about her son's mental state, and he was not taking his medication. Consequently, Mr G was contacted again, and he decided to visit Mr A on the ward that morning.

At 10.20am on 11 July, Dr I reviewed Mr A and it was decided to discharge him, with a prescription for a further 10 days' antibiotics. However, Mr A left the ward without taking his prescription, stating that he would return to collect it. He did not return.

A discharge summary was written, which gave details of Mr A's treatment. There is no record where the summary was sent, and no record of any planned follow-up.

When Mr G arrived on the ward to undertake his further assessment, Mr A had left the ward. The subsequent mental health record states: "Mother aware and expressing her concern."

Dr I summarised Mr A's care during this admission:

"He had been assessed by Psychiatric liaison and he had been … a model patient. While accepting that the combination of schizophrenia, Addison's disease, recreational drug overdose and pneumonia is a high risk situation, [Mr A] was kept in hospital for more than 72 hours and responded well to treatment."

After discharge - 11 July 2005

Mr A called his mother at work at about noon on 11 July to say that he had been discharged. She asked how he was and "he said he was quite wheezy and felt weak". They agreed that he would call her again that evening after she had finished work.

At 2.07pm, Mr A's prescription and discharge summary were sent by facsimile to the Consultation Liaison Psychiatry department. The cover sheet stated:

"Sorry we missed reviewing [Mr A].

His discharge summary and script follow (apparently he told the ward he would return to get his script - he hasn't at this stage)."

Mrs B stated:

"[Mr A] phoned twice on Monday evening. … [Mr A] was significantly more distressed than I [had] seen him on any previous occasion. He was typically verbally aggressive when unwell however on this occasion he mostly cried and pleaded for help. He said he was too sick to be on the streets and said he was going to die that night, what sort of mother was I that I would not agree to help. The help he was seeking was an undertaking that I would not contact anyone from mental health, the hospital or the Police. He implied that if I were to give that undertaking he would tell me where he was.

During our phone conversation [Mr A] spoke irrationally. He spoke about paranoid ideas and feeling desperate. He was exceptionally distressed and his demeanour was out of character. He believed that nursing staff [had] been poisoning his medicine and that [mental health staff] were evil. [Mr A] was usually staunch and aggressive. In this conversation he cried and pleaded and expressed considerable fear."

Mrs B ended the conversation with her son so that she could contact the Crisis Team. The Crisis Team asked her if she would be willing to have her son home if they could get him to take his medication. She subsequently stated:

"The situation was significantly more serious than simply convincing [Mr A] to agree to further medication. I explained that I had not previously heard [Mr A] so distressed and that I was really concerned. I was very conscious that it was a particularly cold wet night, [Mr A] had no money, no accommodation and was not fully recovered from pneumonia. The Crisis Team … suggested I call them back if [Mr A] called again and I was able to locate him. [Mr A] did not make contact again. The conversation at approximately 7pm was my final conversation with [Mr A]."

Mrs B continued to contact the outpatient team as her son had not been in contact, and the Police were involved to find him.

A few days later, Mr A was found dead.

Relevant DHB policies

Self-discharge

The DHB has a policy (dated December 2002) relating to the actions to be taken by staff when a patient chooses to discharge him- or herself against medical advice. The policy states that such a patient should complete a self-discharge form, and the patient's decision to self-discharge (including any refusal to fill in the above form) should be documented in the clinical record. Next of kin should be advised of the patient's decision "and/or the Police where it is likely the patient is at risk from self harm or could do harm to others".

Discharge planning

The DHB policy Discharge Planning (March 2004) states:

"…

1. Consumers'/kiritaki needs and support requirements are assessed in a comprehensive and timely manner.
2. Consumers/kiritaki receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcomes or goals.
3. Consumer/kiritaki … support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet the consumer's/kiritaki needs. A record of this is maintained.
4. Service providers identify, document and minimise risks associated with each consumer's/kiritaki exit, discharge or transfer including expressed concerns of consumer/kiritaki, family/whanau or other representative where appropriate.

Service providers facilitate a planned exit, discharge or transfer of consumers/kiritaki that is documented, communicated and effectively implemented."

Follow-up by the DHB

Serious incident review

A serious incident review was performed by the DHB following Mr A's death. The review identified that, in hindsight, it may have been better if Mr A had been detained in hospital. However, the review noted that "there is a significant lack of facilities for medium term or long term rehabilitation outside of the forensic sector".

The review also noted that the clinicians in the Hospital would not have had full access to the mental health records because of the two separate electronic medical record systems used by the mental health service and by hospital staff. Accordingly, "there [were] not detailed alerts or flags with regard to the degree of non-compliance … from the mental health side to the physical health side".

It was also noted that Mr A had two NHI[7] numbers and thus two sets of medical records, because of a variation in the spelling of his name.

Actions recommended as a result of the review included:

"…

• Communicate weakness of alert system to existing project group looking into improving alerts.
• Communicate to Information Manager weakness of NHI duplication potential.
• Continue to review with planning and funding groups the need for more locked rehabilitation beds."

Detention

The Clinical Leader, DHB Mental Health Services, advised:

"[T]he option of locking [Mr A] up for a prolonged period had been discussed between the clinical team, [Mr A], and his mother and it was decided that this was not an option to be pursued. The reason for this was [Mr A's] clear choice to lead an extremely independent lifestyle and this choice did not seem to be mainly directed by psychotic thinking. Secondly, [Mr A's] mother was not supportive of this option because of her awareness of [Mr A's] desire to remain free. … In the absence of [Mr A's] agreement there was no point in sending him to [an] unlocked rehabilitation unit. He was not referred to [a] locked rehabilitation unit because his mother was not supportive of this option. … In hindsight it may be regretted that this course was not chosen, but it had certainly been considered during his treatment.

…

Detention is only permitted by law if it is not possible to undertake assessment and treatment as an outpatient. Substance abuse per se is not legally part of mental disorder, and could only be addressed under compulsion where substance use or abuse impacts negatively upon the ability of staff to assess and treat the mental disorder. Detention in order to prevent substance use pure and simple is not permitted. Severity of illness and ability to adequately assess and treat are the determinants of a decision to detain a compulsory patient for the purposes of assessment and treatment."

Health records systems

The DHB advised in June 2008:

"[T]he electronic system for mental health records is designed as a separate system and is not integrated with the main record. We acknowledge that key information should be readily available to the treating clinicians and a Mental Health 'Health Events Summary' is being developed.

Whilst there are some process issues around alerts from mental health services including the fact that some service users do not want their mental health history to be flagged to other providers, the Mental Health 'Health Events Summary' will provide a summary of care that will be readily available (as part of the [DHB] patient record) to other providers during the course of a patient admission or contact."

Coroner's inquest findings

On 2 October 2006, the Coroner released his findings. He stated in summary:

"I begin by recognising that, in my coronial experience, I have not come across a person who posed the difficulties [Mr A] posed to all those, including his mother, who were involved in addressing his health problems. Cataloguing these difficulties would run the risk of 'blaming the victim'.

Several witnesses referred to the questions of the degree to which the Emergency Department and ward staff should or could have prevented [Mr A] from leaving their care the way he did, and of the ability of the Mental Health Service to provide him with custodial care. The short answer, and the one that best accords with the admirable principle of maximising patient autonomy, is that the staff would be at risk of serious criticism if they, in effect, confined him in any way unless with judicial backing. It may be that [Mr A's] survival may have best been furthered by his permanent confinement in a long-term mental health hospital. Such hospitals no longer exist and the decision to close them was as much political as therapeutic. Having said that it is clear that the short-term 'locked ward' beds available to [the] DHB (three only) are plainly insufficient. I hasten to add that to confine him in this way would have deprived him of his freedom and an existence that was unconventional rather than seriously dangerous to others. The dangers to him were more real but I know of no health system that manages situations such as this one in a way that is both fully aware of patient rights and non-coercive.

As far as [the] DHB is concerned I approve of the conclusions reached in the [Serious Incident Report] and I make no other recommendation."

The Coroner made the finding that Mr A had died "on or about [date] 2005 [from] acute bronchopneumonia (complicating Addison's disease) and multiple drug toxicity (methadone, olanzepine and zopiclone)".

Responses to provisional opinion

The District Health Board

The DHB stated:

"We agree that some of the documentation was not fully completed as it should have been. A number of initiatives have been taken both in regard to this case and following your report into Capital and Coast District Health Board.[8]

The Admission to Discharge Planner has been further revised with a streamlines multidisciplinary approach to ensure accuracy of patient information from the date of admission to date of discharge. Completion of nursing assessment and discharge planning requirements are to be identified within 24 hours of a patient's admission to the ward.

There have been ongoing teaching sessions within the unit for staff around documentation, especially the Admission to Discharge Planner. Documentation is raised as a quality issue at regular ward and unit meetings.

There are quarterly documentation audits of the Admission to Discharge Planner conducted in General Medicine, and feedback is given not only to the ward but to the individual nurses.

In recent months we have developed an internal transfer of care form with an individual patient's nursing handover requirements, to establish appropriate and accurate information and plan of care for each patient for patients moving from one service to another. This is a structured set of questions with risk factors and is intended to improve the quality of nurse to nurse handover.

It is unfortunate that the fuller mental health history was not available, however Mr A was competent and his overall management plan was unlikely to have been different. Had this history been available the team would have contacted [Mr A's] key worker. They may also have discussed [Mr A's] care directly with his mother to confirm the discharge plan, but as [Mrs B] reported in her complaint … this was something he had specifically asked her not to do.

Even if the Liaison Psychiatry team had called to see him and the other cross team communication had been improved it is possible that [Mr A] would have left the ward as he did. There was no basis to detain him.

The Liaison Psychiatry team did promptly notify the [outpatient] Team of [Mr A's] departure from the ward.

…

The Serious Incident Review Process for mental health was reviewed and updated in 2007. The process now includes a more rigorous review of the information surrounding the incident and the creation of a timeline of events leading up to the event. … The Family Advisor for mental health services now also makes contact with families and their views and concerns are sought before a meeting is held to discuss the case. A set of measureable and achievable recommendations from the meeting are developed and progress towards achievement monitored.

…

We acknowledge that there were instances where documentation was incomplete. We also acknowledge that communication and collaboration should have been better and that coordination between services could have been improved. [The]DHB has implemented a number of changes to address these issues since [Mr A's] death."

Mrs B

Mrs B stated:

"Thoughts that came to mind in respect of the report pertain to the continual refrain from the various health services that [Mr A] was difficult. I accept and understand he was 'difficult' - however to some extent 'difficult' is simply the nature of the concoction of physical and psychiatric disorders present. I am sure many people with a mental illness are difficult. [The] DHB seem to believe that 'difficult' was/is an adequate explanation, excuse or cover to hide behind. I seriously take issue with their attitude in that respect. Family were accurately aware of just how much [Mr A's] life was at risk. Numerous big red crisis flags were raised by family on numerous occasions. The response was typically '[Mr A] is difficult' or dismissive along the lines of me being an over anxious mother who lacked full understanding of [Mr A's] true physical and mental state. This left family in a truly harrowing situation - watching and waiting for the inevitable - [Mr A's] death."

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

(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.

Opinion: Breach - The District Health Board

Introduction

By 2005, Mr A had serious chronic medical problems on top of his mental health diagnoses, and was often not compliant with his medication regime after he had been discharged from hospital. Compounding these difficulties, he was often homeless (making his follow-up care difficult) and used illegal drugs, including amphetamines and cannabis. However, the clinical teams who were responsible for his care were, or should have been, aware of these difficulties, and should have managed his care accordingly. Although [Mr A's] premature death may not have been prevented, in my view, at the time of his final admission and discharge, he did not receive an appropriate standard of care in accordance with his needs, and District Health Board staff did not co-operate to ensure quality and continuity of services. Accordingly, the DHB breached Rights 4(3) and 4(5) of the Code of Health and Disability Services Consumers' Rights (the Code).

Mental health care

Care in the community

Mr A was subject to a compulsory treatment order from 6 January 2005, initially on an inpatient basis and from 21 February in the community.

On his admission on 6 January it was noted that a major reason for his relapse was that he had not been taking his psychiatric medication. During his admission, Mr A was assessed by psychiatrist Dr D, who concluded that he was "unlikely to adhere to either regular monitoring or regular appropriate treatment without some compulsion to do so". Mr A was subsequently discharged on 21 February 2005 under the care of the outpatient team. His contact with the outpatient team was described as "intermittent". A number of home visits were made, but Mr A was often not there.

Despite Mr A's assurances on 16 March that he did not need assistance finding accommodation, his mother contacted the outpatient team concerned that he had nowhere to live, and worried that he might relapse again. She called again in May, having lost contact with her son again, but in June reported him to the outpatient team as being "better".

Obviously, although subject to a compulsory treatment order, Mr A did not always comply with his treatment in the community. My independent psychiatric advisor, Dr Peter Miller, advised that the compulsory treatment order that Mr A was under was ineffective, and that "the management of his symptoms was not adequate to improve his functioning, personal distress or quality of life".

It appears that medium-term placement in a secure unit was considered, but there was a lack of access to locked rehabilitation and it was considered unlikely to be beneficial, given Mr A's resistance. In these circumstances I consider that the DHB acted reasonably in maintaining Mr A on a community treatment order, despite his periodic non-compliance.

Medical care

6 July 2005

Mr A was admitted briefly to the Hospital ED from 9pm to 11.20pm on 6 July 2005, having taken an overdose of methadone, an opiate drug he had obtained illegally. I have concerns about the quality of care he received during his brief stay in ED.

My independent physician advisor, Dr Geoffrey Robinson, noted that methadone is a long-acting drug that would have remained active in Mr A's body for more than 24 hours. The antidote given, naloxone, has an effective time period much shorter than methadone - no more than a few hours. In simple terms, Mr A was discharged when there was still a risk to his health. Although he appeared to be well, the antidote effect of naloxone would have soon worn off, and the side effects of a large dose of methadone would have reappeared. This is indeed what appears to have transpired, with Mr A being readmitted only a few hours after discharge.

The clinical record indicates that Mr A was unwilling to stay in hospital, and that a subsequent discussion resulted in his discharge. The risks of his discharge having consumed a long-acting opiate were not explicitly recorded in the case notes or given in written form to Mr A. There is no evidence that Mr A was told of the potential danger of the continuing effects of methadone. This was poor practice.

7-11 July 2005

When Mr A reattended only a few hours after discharge, he received appropriate treatment in ED (including an ECG and the measuring of toxicology levels), and was ultimately admitted to a ward for care over the weekend after pneumonia was diagnosed. Mr A's medical care appears appropriate, subject to the concerns discussed below.

Discharge planning

I am concerned at the discharge planning process prior to Mr A's discharge on 11 July, and the lack of communication between the physical and mental health teams. I note in particular the requirement in the DHB's own discharge planning policy, which states:

"Consumer … support for access or referral to other health … providers is appropriately facilitated, or provided to meet the consumer's needs."

The information relating to Mr A's social circumstances recorded in the clinical documentation was flawed. It specifically states that he lived with his mother, and that there were no problems with accessing accommodation or money after discharge. The documentation also states that there was no requirement for ongoing support after discharge. Other sections were not completed - relating to whether there was a risk of self-harm, and whether Mr A could manage at home after discharge. I also note that the subsequent discharge summary mentions no concerns about the difficulties faced by Mr A after discharge.

There is no record in the ward clinical notes of the review on 7 July by Clinical Nurse Specialist Mr H from Liaison Psychiatry. In addition, the electronic notes made by the mental health team were not available to the ward staff as they were maintained in a separate system.

Although Mr H returned to see Mr A on 8 July, he had been transferred to the ward by this stage. Mr H assumed (and recorded) that Mr A had discharged himself. It was subsequently discovered that Mr A had two NHI numbers, which may have explained why Mr H could not "find" his client.

There is no record of the ward staff contacting psychiatric services for advice or a discussion prior to Mr A's discharge.

It was known by the psychiatric services that Mr A had a history of non-compliance, and that there were significant social problems relating to his support in the community. However, this information was not communicated to the ward staff caring for Mr A or discussed prior to his discharge. It seems that the discharge proceeded on the basis of the erroneous information recorded on Mr A's admission, that there were no problems at home.

Finally, Mr A was discharged, and chose to leave the ward without collecting his prescription for antibiotics, saying he would return for it, but not doing so. However, the ward did not call the psychiatric team, who found out later that day when Mr G visited the ward to see Mr A.

I endorse Dr Robinson's advice:

"I believe that the high risk status of this patient should have been recognised by the medical and psychiatric services. This should have engendered vigilance around discharge planning and communication between these services but there is no documentation that supports that this occurred even when [Mr A] left the ward before collecting his prescription and failed to return."

In my view, Mr A's discharge on 11 July was inadequately managed. There had been insufficient discussion between the mental and physical health teams, and the risks associated with Mr A's discharge were not appreciated and responded to.

The information obtained about Mr A's social circumstances was significantly incorrect. Accurate information would have influenced the discharge planning.

The DHB advised in June 2008 that it is still in the process of developing a Mental Health "Health Events Summary", which will "provide a summary of care that will be readily available … to other providers during the course of a patient admission or contact". I note that the Coroner's findings (2 October 2006) approved the recommendations of the DHB Serious Event Review (25 October 2005), which included a need for "the new risk assessment system results in mental health alerts being more visible within the mental health system and this will subsequently be interfaced [with] the general hospital based system". It is concerning that, almost three years after Mr A's death and the DHB Serious Event Review, and almost two years after the Coroner endorsed the recommendations made, the DHB has still not resolved this issue.

In my opinion, greater effort should have been made by the mental health team to inform the hospital staff of the specific problems that would be faced when Mr A was discharged - particularly in relation to his home circumstances, lifestyle, and compliance with medications.

Summary

I am critical of the DHB's failure to advise Mr A of the risks posed by the continuing effects of the methadone overdose in his body at the time of his discharge at 11.20pm on 6 July 2005, and to document accordingly. Furthermore, by failing to plan Mr A's discharge adequately on 11 July 2005, and to ensure that the mental health team and the physical health team discussed his ongoing care after discharge, the DHB failed to provide properly co-ordinated services in a manner consistent with Mr A's needs. In these circumstances, the District Health Board breached Rights 4(3) and 4(5) of the Code.

Recommendations

I recommend that the District Health Board:

• Apologise to Mrs B for its breaches of the Code.
• Advise HDC by 31 July 2008 when it is expected that the Mental Health "Health Events Summary" will be in place.

 

Follow-up actions

• A copy of this report will be sent to the Director of Mental Health.
• A copy of this report, with details identifying the parties removed, will be sent to the Royal Australasian College of Physicians, the Australasian College for Emergency Medicine, and the Royal Australian and New Zealand College of Psychiatrists, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

 

Appendix 1

Expert physician advice - Dr Geoffrey Robinson

"Thank you for requesting my opinion as an independent adviser on this complaint. I have read and agreed to follow the Commissioner's guidelines for independent advisers. [At this point Dr Robinson states the advice asked of him. These questions are repeated in his report, and have been omitted for the purpose of brevity.]

Qualifications, training and experience relevant to aspects of this case:

I am a registered Medical Practitioner (MBChB 1972). I undertook physician training, gaining a Fellowship to the Royal Australasian College of Physicians (FRACP) in 1979. From 1978-1980 I undertook a residency training programme in Drug and Alcohol Medicine at the Addiction Research Foundation, Clinical Institute, affiliated to the University of Toronto, Canada. From 1980 to 2003 I was the Senior Clinician in the Capital & Coast Drug & Alcohol Service (0.5 FTE). Since 1982 to the current time I have been the physician responsible for the inpatient Detoxification Unit at Kenepuru Hospital. I was on acute general medical duties at this Hospital from 1980 to 2003 and am familiar with medical wards. In 2002 I became a (Foundation) Fellow of the Australasian Chapter of Addiction Medicine, FAChAM (RACP). I am familiar with patients with drug and alcohol problems, and drugs of abuse potential. I am also familiar with patients with co-existing addiction, psychiatric and medical disorders. I am currently the Chief Medical Officer (0.7 FTE) of Capital & Coast District Health Board. [It should be noted that I have not worked specifically in an Emergency Department for many years.]

Standard of care provided to [Mr A] at the Emergency Department, 6 July 2005:

The clinical record shows that [Mr A] was attended by ambulance staff at 8:21 p.m. who found him in a state of considerably reduced levels of consciousness and pinpoint pupils. [Mr A] responded to treatment for a suspected overdose of opiate (narcotic) drugs, this being ordinary doses (0.4 mg total administered at 8.28-8.32 p.m.) of naloxone. This is an opiate antagonist drug which reverses the effects and clinical signs of most opiate drugs including methadone.

[Mr A] was taken to the Emergency Department where he was found to be alert, and remained so for the rest of his stay there (until about 11:20 p.m.) I note the psychiatric services were notified of his attendance during this period in the Emergency Department. [Mr A] was given usual clinical investigations and treatment of his Addison's disease, this being blood sugar, electrolytes and intravenous Hydrocortisone and fluids.

[Mr A] advised (documented at 9:30 p.m.) that he had taken 'IV methadone tonight'. It is recorded that [Mr A] was fully alert and 'talking sense' at 11:00 p.m. and that he 'did not wish to stay in hospital'. He was given advice about hypoglycaemic (low blood sugar) symptoms.

Reading the case notes it does not appear to have been appreciated, or documented that the patient could have been at ongoing risk for methadone overdose. An explanation of this may have been that the patient did not require ongoing doses of naloxone and remained alert for 2 ½ hours following the initial naloxone administration, but there is no documentation about this.

Methadone is a very long-acting drug which remains in the system for more than 24 hours. The half-life is reported as being 27 +/- 12 hours. Half-life refers to the time it takes for the plasma concentration or the amount of drug in the body to be reduced by 50%. The antidote (naloxone) has a shorter duration of effect of not more than a few hours. The half-life of naloxone is reported as 1-1.5 hours.

It is important that patients with significant methadone overdose are kept under observation so that they can be provided with ongoing naloxone, either by regular injections or continuous intravenous infusion.

This medical knowledge is generally well known to emergency department staff, whether for methadone overdose or other opiates, eg morphine of lesser duration of action (personal communication with Dr P Freeman, FACEM, Clinical Leader of Emergency Department, Wellington Hospital). It may be that the emergency department attended by [Mr A] has a protocol for opiate overdose (and I note a naloxone infusion was the treatment instituted when the patient re-presented on 7 July 2005).

The National Poisons Centre can be accessed by clinicians and ED departments. I have downloaded the National Poisons Centre and TOXINZ information (attached) which refers to guidelines for the treatment of methadone over-dosage.

The relevant sections for your information are page 6/19 (naloxone), page 8/19 (respiratory depression, pulmonary aspiration), and page 10/19 (discharge criteria). These latter discharge criteria state 'Methadone, LAAM and other long lasting opioids have a duration of action greatly exceeding that of naloxone and other opioid antagonists. It is important to be aware that reversal will be short term only, and toxic effects may reappear when the antagonist wears off. Consideration may be given to discharge provided the patient has been symptom free for 8 hours after cessation of treatment with an opioid antagonist, and provided the patient is not suffering complications of their opioid overdose.'

As above, it does not seem to have been appreciated from the Emergency Department records that the patient could have been at ongoing risk for methadone toxicity as there is no documentation of this issue in the notes. If it had been appreciated, then the patient would have needed to have been fully informed of the risks when he stated he wished to leave the department. These risks could have been sedation, reduced level of consciousness and coma, inadequate breathing, pneumonia, and death. A continuing wish to discharge himself in the face of such advice would have generated earnest consideration by the clinicians in the Emergency Department of [Mr A's] competency and decisional capacity, as well as the risks given his homelessness, recent methadone self-administration and psychological disorder. This is a difficult clinical and legal matter. It is possible that [Mr A] was competent and non-incapacitated (with the methadone effects reversed). He was stated to be 'not acutely psychotic' at 11:00 p.m. in the Emergency Department. The principle of self-determination is recognized, but this situation would likely have required a psychiatric clinician review for a patient under the Mental Health (Compulsory Assessment and Treatment) Act. This was not sought. If he had been judged fit to discharge himself, and the risks appreciated, the ED should have attempted to ensure that he was with someone who could have observed him in the community.

In this regard I note the expanded discussion of these issues in the letter to the HDC of 7 November 2007 from the DHB. This reports that the patient was judged legally competent on 6 July 2005. I note the Coroner has commented on this aspect in his decision of 30/8/2006 on page 5 para [II].

As above it is not documented in the notes that the methadone risks to [Mr A] were appreciated or that he was informed of them. (The lesser risks in my view of low blood sugar from Addison's disease were documented.) The Emergency Department phone report on 6 July 2005 to Mental Health suggested he would be discharged home 'probably in the next hour or two'. Also, the Emergency Department discharge form does not use the self-discharge section but ticks 'home alone' and by 'taxi' in the discharge section. If [Mr A] discharged himself, then aspects of the 'Self-Discharging Patients Policy (qv)' are important, eg advise the next of kin and police when the patient is at risk of self-harm.

Other clinical issues evident from the records were that there were only two sets of vital signs during the patient's emergency department stay, and oxygen saturations seem to have been done only on arrival. There did not seem to be any toxicological testing performed ie blood and urine drug levels following the collapse attributed to overdose. However the management of acute opioid poisoning is based on clinical observation. An electrocardiogram (ECG) was not done but would have likely been indicated in a patient with collapse, overdose, and on psychiatric medication. (The issue of methadone prolongation of QT interval on ECGs was publicized … in November 2005.)

Regarding the pneumonia, it is accepted that the patient did not have symptoms, fever or clinical signs of this on respiratory examination. His low oxygen saturations on admission to ED would likely have been ascribed to overdose-induced respiratory depression.

There was no documented clinical history on the patient's drug use history, amount of methadone, frequency of use or why he accidentally overdosed on this occasion. This may have been due to patient lack of co-operation.

Comment

From the case notes, it seems likely that the significance of the methadone over-dosage and its propensity to re-emerge after the antidote naloxone's protective effect had dissipated were not properly appreciated by the emergency department staff, and the patient was thus permitted to leave. Conversely if this situation had been appreciated, then it was not documented. Neither was it documented that [Mr A] had been fully informed of the risks. His competency may not have been assessed in appropriate depth given the multiple risks and his Community Treatment Order under the Mental Health Act provisions. 'Self discharge' procedures were not followed with regard to notifications to protect the patient.

Management of his Addison's disease was of a satisfactory standard and the clinical assessment for his pneumonia was probably adequate.

However, I had concerns that there were areas of deficiency in regard to the clinical history taking, investigations (electrocardiogram, toxicology) and vital signs monitoring. It is unclear to whom the emergency discharge summary was sent which ideally should be to the general practitioner and the mental health services.

Considering these factors, particularly those in the first paragraph above (based on a clinical record review), I would say that the overall standard of care was moderately below that expected for this clinical presentation.

Care Provided to [Mr A] following his readmission on 7 July until his Discharge on 11 July 2005:

[Mr A] re-presented at the instigation of the Police, having been found 'unwell'. He had pinpoint pupils, slow respirations and sedation, which were consistent with methadone effects.

Review of the Emergency Department records after [Mr A] arrived back in the Emergency Department around 3:00 a.m. illustrates that the various management issues previously identified were attended to with alacrity. This included regular observations and an array of investigations which included blood gases, toxicological testing, electrocardiogram, chest x-ray and a CT head scan.

He was commenced on naloxone which was continued regularly, as well as steroids.

The initial chest X-ray review by [an ED doctor] was reported as 'nil obvious aspiration' 7 July 2005 at 0900, but at 2200 'the chest X-ray confirms aspiration' ([another ED doctor]). Tachycardia and fever had emerged at this time. Augmentin was prescribed (despite the penicillin alert on the chart). [Mr A] was reviewed over the weekend and noted to be improving with resolution of the fever. There is no nursing comment during the admission to suggest mental health issues emerging or the presence of a drug withdrawal syndrome.

I note the 'reassuring' liaison psychiatry report of [9.51pm] on 7 July 2005, and presume this would have been available to the medical team. It appears well known to the psychiatric services that [Mr A] was a polydrug user. I am unable to find a detailed drug/alcohol history in the case notes. In particular, it seems unclear how often he took methadone or other drugs, but there was a subsequent case note comment that he took 60 x 5mg methadone tablets which is a very large dose even for a tolerant regular user. I note the toxicology of 7 July 2005 which was a urine drug screen, and blood Paracetamol and alcohol levels. No blood methadone level was done despite this being the admitted drug used.

I note the two hospital numbers [x] and [y] on the discharge summary. The past medical history may thus have not been initially fully available to the admitting medical team. However, the recent admissions for Addison's disease may have been appreciated as [Dr I] had attended him during the April 2005 and May 2005 admissions.

It was known to the admitting medical team that [Mr A] was 'poorly compliant' and under the provisions of the Mental Health Act, as this was listed on information on the discharge summary.

Regarding discharge issues, it is not clear to whom the discharge summary was sent. I would have expected this to have been sent to the community psychiatric services as well as the general practitioner. No arrangement appears to have been made to follow up [Mr A's] recovery from the pneumonia and usually an arrangement for a repeat chest X-ray would have been made albeit about six weeks post discharge.

It is noted [Mr A] left the ward on 11 July 2005 without collecting his prescription, and before a possible planned psychiatric liaison review.

Comment:

Overall the management of the medical issues of the methadone overdose, Addison's disease and pneumonia in the Emergency Department and in the medical ward appeared to be of a good standard with good documentation and good diagnostic listings and treatment plans.

The issue of discharge-planning merits some attention. It appears from the nursing form of 9 July 2005 ([an] RN) that [Mr A] lived with his mother. This form in retrospect appears incompletely filled out and does not inspire confidence that [Mr A's] social situation had been appreciated. One might be concerned that this 'protocolisation' may in fact inhibit sensible planning as this might be developed with a bedside conversation with the patient. It would have been known to the medical team that [Mr A] was homeless if the liaison psychiatry report of 7 July 2005 was on file and/or read. On many medical wards there are multi-disciplinary team meetings whereby the wider social aspects of complex patients and their discharge planning are discussed. There is no documentation of such a meeting, however the patient was admitted on a Friday morning and discharged on a Monday morning, so there was probably no time for such a multi-disciplinary team meeting.

It is appreciated that the patient was cooperative with medical treatment during this admission and there was no clear evidence of psychiatric instability perceived by the ward staff (as opposed to the patient's mother). In addition the liaison psychiatry report was reassuring about [Mr A's] 1/7/05 review, and did not draw the medical team's attention to the significant issues and management difficulties of his psychiatric (or medical) problems over the first six months of 2005. Nevertheless there were some alerts, including the discharge summary from the Emergency Department of 6 July 2005, and concerns of him absconding on 8 July 2005 from the medical ward with an IV line in situ.

There are various other components of the discharge policy including planning and partnership with the caregivers or family. It is possible a more coordinated discharge plan would have been developed and communicated if he had been seen by the psychiatric liaison service before he left the ward. However, this did not occur after the patient unexpectedly left and did not return to collect the prescription. Given the risk issues of Addison's disease and pneumonia this situation should have prompted some alarm and actions by the ward with regard to contacting the psychiatric liaison services and the patient's mother, but there may be privacy concerns with the latter. It was known to the medical team that [Mr A] was 'poorly compliant' and under a compulsory treatment order of the Mental Health Act, as this is referred to in the excellent diagnostic listings of the discharge summary. Again, there is no indication of to whom the discharge summary was to be sent, but it should have been the GP and the community psychiatric service.

I note that the psychiatric services knew [Mr A] was being observed as in their 'log' of 7 July 2005. The file entry of 8 July 2005 by liaison psychiatry appears cursory and states that '[Mr A] has gone from the Department of Emergency Medicine, so I assume he discharged overnight', when in fact he had been admitted to the medical ward. The reasons for this are unclear but as later in this report could be related in part to the duplicate NHI numbers if there was attempted tracking of this patient. It seems unclear whether psychiatric liaison had become aware that [Mr A] had been admitted to the medical ward. There appears to have been a disconnect or lack of understanding of the situation between the medical team and psychiatric services.

I believe that the medical treatment of [Mr A's] methadone overdose, Addison's disease and pneumonia were in themselves at a satisfactory standard during this admission.

Despite the issues with the two NHI numbers I believe that the high risk status of this patient should have been recognised by the medical and psychiatric services. This should have engendered vigilance around discharge planning and communication between these services but there is no documentation that supports that this occurred even when [Mr A] left the ward before collecting his prescription and failed to return. It would seem that with regard to the issues of discharge planning and service coordination that there were aspects mild-moderately below the expected standard for this predictably at risk patient.

Medical management of [Mr A's] alcohol and drug use:

There is no detailed drug/alcohol use history documented, not even in the psychiatric liaison assessment of 7 July 2005.

I note that the alcohol withdrawal protocol was ordered at one point early in the second admission but there is no evidence that this was instituted possibly because it did not appear to be subsequently necessary as [Mr A] did not appear to exhibit alcohol (or drug) withdrawal signs in the Emergency Department or subsequently in the ward.

Thus, [Mr A] was likely a sporadic polydrug user who was not physiologically dependent on alcohol, opiates or other drugs. (Alternatively he could have continued to access drugs during the ward stay and thus suppress withdrawal.)

I would say that medical and other wards would likely mostly consult specific Alcohol and Drug Service advice when patients were exhibiting drug/alcohol withdrawal symptoms. It might be usual practice in some hospitals for psychiatric liaison to incorporate the identification of alcohol and drug issues and organise access to Alcohol and Drug Services. There was an expectation by the medical ward that psychiatric liaison would have been revisiting [Mr A] during the admission. The ward staff would not have been aware that [Mr A] rejected alcohol and drug referral in the past.

In any event [Mr A] had a life-threatening excessive dose of 'street' methadone but there is no documentation of intervention about this or at least 'harm-reduction advice'.

In summary I would suggest that the standard of care by the medical team was acceptable in that there was not the usual trigger for Alcohol and Drug management advice of withdrawal symptoms, and there was an expectation of further psychiatric liaison input.

Finally, I note this patient was a tobacco smoker who continued to smoke when well enough despite his pneumonia. I cannot see that nicotine replacement treatment was offered or charted, as might be expected. He was however advised to cease smoking on discharge.

Coordination with psychiatric services of [Mr A's] care in relation to his admissions on 6 and 7 July 2005.

In the perusal of the records it is noted that it is commendable that psychiatric services were notified on [Mr A's] first presentation to the Emergency Department and that secondly he was reviewed in the Emergency Department the next evening, and that this report was available to the hospital file and community psychiatric services. As previously in this report there was a problem on 8 July 2005 when psychiatric services incorrectly assumed that [Mr A] had again self discharged rather than having been admitted to the medical ward.

According to the Coroner's decision (finding 2 October 2006) I note 'this is partially explicable by the two hospital numbers' issue page 3, paragraph 6. It is of interest in this paragraph that there was a fax sent by psychiatric liaison to the [outpatient] team after [Mr A] had left the ward noting that '[Mr A] had told the ward he would return to get his prescription'. This implies that the psychiatric liaison may have visited the ward after [Mr A] left, or alternatively the ward contacted psychiatric liaison and advised of the situation relating to his departure (and intention to return for the prescription).

The issue of the two hospital numbers may explain the mistake that [Mr A] was not immediately known to have been admitted. I am uncertain from the documentation as to whether the psychiatric liaison knew that [Mr A] was an inpatient or not and whether they were scheduled to visit on 11 July 2005, or whether the ward informed psychiatric liaison of the prescription issue. It is difficult to offer a view on the 'admission mistake' without further detail. The Coroner has commented on the two NHI number issue (paragraph 10) in his decision.

Conclusions made by [the DHB] following the internal review:

This report was completed three months after [Mr A] died and was correctly designated as a 'serious event'. It does not indicate a process for the review or represent the roles of those 'present' which seem to have included a mixture of some attending clinicians with others. It is unsure whether an 'external' person was on the panel. It is unclear if there was a process of interviewing of clinicians or root cause analysis approach.

However there was a reasonable overview of [Mr A's] complex health situation, his major management challenges and the treatment situation at [the] Hospital prior to his death. Some of the issues which have come to light as part of this HDC investigation (initial Emergency Department treatment, leaving the ward without the prescription, and discharge planning) appear not to have been appreciated or addressed. There was no apparent attempt to engage the family, in particular [Mrs B] (mother) who would likely have had an array of concerns, in the review process.

(It is appreciated that the process of serious event reviews has been iterative for DHBs, and standardisation and guidelines are probably only now being developed by the National Ministry of Health QIC Committee following recent media publicity on this issue.)

The review panel may not have addressed some specific issues such as how to secure a better and coordinated treatment plan using the opportunity of [Mr A's] hospital admission given his extreme vulnerability and multiple risk factors of pneumonia, Addison's disease, psychiatric illness, drug abuse, homelessness and poor compliance.

The panel identified some systemic issues which could have contributed to the difficulties encountered. Recommended actions should have ideally included 'by whom' and a timeline.

Other comments:

The comments offered are on the basis of reading various reports and the case notes only.

The deceased patient who is the subject of this investigation was clearly at the most difficult end of the management spectrum, and the comment of [the] Coroner in his decision is noted. 'In all my coronial experience I have not come across a person who posed the difficulties [Mr A] posed to all those, including his mother, who were involved in addressing his health problems.'

There are a number of recurrent themes brought to focus by the selected national Coroner's cases circulated to chief medical officers, as well as published HDC cases. These include: The 'marginalised patient' as the HDC refers to them, involving psychiatric patients in medical services and their liaison and management issues; 'Psychiatric patients' with coexisting addictive disorders (including tobacco smoking); and thirdly methadone which seems overly represented in coronial cases. This opioid causes particular dangers by virtue of its long duration of action and recently established cardiotoxicity.

A final issue may be the dispensing of large amounts of potentially dangerous medications to patients who are at risk of misusing these.

G M Robinson"

Appendix 2

Expert psychiatry advice - Dr Peter Miller

"I have been asked to provide an opinion to the Commissioner on Case No. 07-08795.

I have read and agree to follow the Commissioner's guidelines for independent advisors.

My qualifications are MBChB Otago 1969, Fellow of the Royal Australian and New Zealand College of Psychiatrists 1991(FRANZCP).

From 1992 until 2003 I was employed by the Canterbury District Health Board as a Specialist Forensic Psychiatrist and in the course of that work, examined a large number of offender patients, in prisons and hospitals, and prepared many psychiatric reports for the court. For the past five years I have worked as Clinical Director of Psychiatric Rehabilitation Services and Intellectual Disability Services and have taken part in a number of inquiries into adverse events. I have also investigated adverse events in psychiatric services in other parts of New Zealand. I also have a position on the Ethical Practice Committee of the RANZCP.

The purpose of this report is to provide independent expert advice as to whether the staff of [the] DHB provided anappropriate standard of psychiatric care for [Mr A]. The particular focus of the report is on [Mr A's] care [over a period of seven months in] 2005. I will also address the following questions:

[At this point Dr Miller sets out the questions asked of him - which he repeats in his report - and the documents sent to him. This has been omitted for the purpose of brevity.]

Illness course January 2005 - July 2005

[Mr A] was admitted to [the Mental Health Unit] 6 January 2005 following an admitted period of some weeks of non-adherence with prescribed medication for Schizophrenia and Addison's disease; heavy cannabis and alcohol use, and a report from his mother of an abnormal mental state, including a number of symptoms and behaviours suggestive of psychosis eg delusions that he had AIDS & Bowel cancer; that he was being followed by police). He also suffered from Addison's disease (with an admission to hospital a month earlier) & Hashimoto's disease. It was recorded that he was homeless and unemployed, and was estranged from his sister and there were tensions between him and his mother. His drug use was reported to include marijuana and 'P' (an amphetamine), last use 3 weeks earlier.

He was moved to an open unit after 3 days, and spent more than 6 weeks as an inpatient during which significant symptoms of his illness were striking by their apparent absence or minimal display.

Signs which nursing and medical staff would expect to see in someone experiencing a relapse of schizophrenia were minimal, and contrasted with what his mother had reported about these core features of his illness prior to admission.

He was seen by the 'dual diagnosis' team, who focus on patients such as [Mr A] with psychosis and substance use.

Discharged 21 February 2005 to be followed up by [outpatient] Team and subject to a community compulsory treatment order (CTO). The only change in treatment was an increase in Olanzapine to 15mgm to be taken at night. He also was prescribed replacement steroids for his Addison's disease to be taken orally, morning and night.

Community Follow-up Following Discharge on 22 February 2005

Summary of Community Follow-up February to July 2005

He was seen on 21 February by [his new consultant]. [Mr A] gave staff his new address, reported that his weekend leave went well and medication needs were established. He was discharged under Section 29 of the Mental Health Act. His [Key Worker] attempted to contact him the following day but [Mr A] was not at home. The following day [the Key Worker] received a call from [Mr A] saying that he would be leaving and absent for the next four weeks and an arrangement was made for him to pick up a prescription from [a community mental health centre] and to contact the outpatient team on return. He actually travelled to [another city] in the mistaken belief that his father was there.

He was next seen on 16 March by another case manager and by his community psychiatrist. He had by then left his accommodation and was staying with his mother. Attempts at follow-up over the next few weeks were made. Contact was mainly by telephone with his mother, [Mr A] having been unavailable, cancelled appointments were not able to be found. He was however seen on 1 July for review of his mental health act status, being seen by his associate Key Worker and [his new consultant], and his mother was also contacted that day.

The next event in his illness was a medical admission on 6 July when he was admitted to the Emergency Department after being found collapsed at a shopping centre. He was thought to have taken a methadone overdose, treated with Naloxone and discharged one and a half hours later, only to be readmitted three hours after discharge. On this occasion he was found to be suffering from pneumonia. He was seen by the clinical nurse specialist from the liaison psychiatry team soon after that admission on the evening of 7 July. He spent 3 days as a medical inpatient receiving antibiotics and discharged himself at 0900 on Monday 11 July.[9] He had telephone contact with his mother the following day but was not seen by anyone, family or staff, until he was found dead by police in a boarding house [a few days later].

• Contacts with his mother during this four and a half month period were mainly by telephone.
• On 24 May, mother reported that [Mr A] had had two presentations at Emergency Department with Addisonian crises; his conversation with her being characterised by paranoia about underage prostitutes and being followed by police.
• On 10 June telephone call to mother and she reported her son to be better.
• On 24 June [Mr A] cancelled his appointment with his case manager.
• Face to face contact with [outpatient] team on two occasions since discharge.
• Examination by psychiatrist on 1 July. At that meeting [Mr A] revealed that he frequently changed boarding houses, was short of money, was still using alcohol and drugs and was gambling, and reporting being well. On that occasion he both admitted and denied symptoms in response to questions from psychiatrist.
• An appointment was made for the 4 August, two-weekly reviews to be continued by his case manager.

First Presentation to Mental Health Services

1. On the 24 April 2000, [Mr A] was admitted to the Psychiatric Unit of [the] Hospital. He was found to be suffering from a psychosis which was thought to be drug induced. He was discharged on the 7 June 2000.
2. He was next admitted to [another] Psychiatric Unit between 15 April 2002 and 8 May 2002.
3. His third admission was in [the first hospital] on the 11 of December 2002 under the Criminal Justice Act. He faced a charge of threatening to do GBH, and was examined by a psychiatrist while in custody on remand who expressed no doubt about his primary diagnosis of schizophrenia. He was discharged from that admission on 15 January 2003.
4. He was next admitted to [the] Hospital psychiatric unit on 29 April 2003 for a period of one month.
5. His last psychiatric admission was for a period of six weeks at the beginning of 2005.

Relevant Early Developmental History

[Mr A] was born in [a large city]; he has one younger sister. When he was about 11 years of age his parents separated and he lived with his father initially, later on with his grandparents. Behavioural difficulties became evident in early adolescence when he began using nicotine, cannabis and alcohol, and also began involvement with the police from age 13 for robberies, burglaries and car theft. He had had a number of suspended prison sentences, the most significant offending took place in November 2002 when he was remanded in custody on a charge of threatening to do grievous bodily harm. At that time he received a psychiatric examination by [Dr C], consultant psychiatrist. [Dr C] considered that [Mr A] was suffering from an abnormal state of mind which included delusions and auditory hallucinations. It was his firm view that [Mr A] suffered from a chronic psychosis, schizophrenia, complicated by alcohol and other drugs and Addison's disease. It was his view that [Mr A] needed Inpatient Treatment at that time and that his offending was closely linked to relapse of his mental illness.

Early Developmental Difficulties

Reports from [Mr A's] mother indicate behavioural difficulties from childhood, and by early adolescence he was involved in offending which came to the attention of the police and was using alcohol and multiple other drugs. He had a number of court appearances and suspended sentences. At the age of 21 years he developed Addison's disease, a serious medical disorder in which replacement steroids taken twice daily by mouth are required and if many doses are missed can result in serious collapse or death.

Summary of Illness History:

At the age of 24 in Easter 2000 he developed over a relatively short period of time, a psychotic illness which resulted in admission to [Hospital]. This was thought to be a drug induced psychosis. The following year he suffered a head injury as the result of an assault and spent a week in [Hospital]. In April 2002 during the [admission], his psychotic relapse was again attributed to illicit drug use and his Addison's disease. Subsequently attempts at follow-up had been made by the [outpatient] team of [the] DHB but it was not until examination in custody by [Dr C] at the end of 2002 that a firm diagnosis of schizophrenia was made. By then, at the age of 27, [Mr A] had a number of disorders:

1. Anti-social Personality Disorder
2. Poly-substance Abuse and Dependence, including 'P'
3. Schizophrenia
4. Addison's disease
5. Hashimoto's disease.

Follow-up in the community was attempted over the next two years but [Mr A] continued to be elusive, although had contact with medical and psychiatric services during a number of admissions for Addisonian crises when he was medically ill. Complicating the task of treatment teams apart from [Mr A's] evasive behaviour was his capacity to conceal symptoms, or minimise them and to recover promptly or at least improve significantly when hospitalised when he was free of drugs and adhering to prescribed medication.

Opinion

In the course of this opinion I will comment on certain aspects of his developmental history, diagnoses, community management and inpatient care. I will also make reference to views expressed in some of the reports I listed at the beginning of this report. I will not comment specifically on management of his medical disorders.

1.   Adequacy of psychiatric care provided to [Mr A] from 1 January - [his death] 2005

During that January/February admission of about six weeks the treatment team had the opportunity to review the course of his primary illness, schizophrenia and other disorders over the preceding three years. I would have expected a family meeting which included his mother, sister and perhaps other persons who knew him. There is also no mention of a second opinion on his management from another psychiatrist (recommended practice with such problematic cases).[10] The discharge summary prepared by the Psychiatric Registrar was a brief two page document which did not contain the level of detail and analysis of the treatment dilemmas I would have expected.

2.   The Appropriateness of Community Management

My judgement from reading the entries by case managers is that staff made adequate attempts to contact him, observe his mental state and attend to his expressed needs. This could not be achieved because of his lack of cooperation in the lifestyle he led and his use of alcohol and drugs and attitude to follow up. The compulsory treatment order was thus ineffective.

3.   It follows that the management of his symptoms was not adequate to improve his functioning, personal distress or quality of life.

4.   Management of his alcohol and drug use likewise could not really be managed without good control of symptoms of his illness and more regular access to him.

5.   Medical admissions on 6 and 7 July 2005

[Mr A] was admitted late on the evening of 6 July with a methadone overdose, discharged after one and a half hours on Naloxone treatment, but readmitted on the early hours of the following morning and this time kept in hospital with a subsequent diagnosis of pneumonia. That first day in hospital (7 July, a Thursday) he was reported (in the medical note) to have been seen by the clinical nurse specialist of the liaison psychiatry team who stated that [Mr A] did not seem acutely mentally unwell. An arrangement was made to see him on the following Monday morning (11 July). However, his departure by nine that morning means that such an assessment did not occur. Given that he was seen by the nurse on the Thursday, I would have thought that would give ample time for that clinician to make further enquiries including contacting his usual follow-up team before the weekend. Unless that was done the assessing nurse would not have had the level of awareness of someone knowing the case well. A phone call may well have made a lot of difference.

6.   Summary and Precis of [Dr D's] Report

[Dr D] in his report dated 5 April 2006 makes extensive comments on almost all aspects of his care in the last six months of his life. He also examined [Mr A] in February of that year during his six week psychiatric admission to determine his need for a compulsory treatment order as prescribed by the mental health act.

It was [Dr D's] view that community care of an adequate standard was not possible given [Mr A's] cluster of disorders and disabilities. In his view [Mr A] required secure Inpatient Care. He also criticised his emergency medical management on the evening of 6 July and the actions of the psychiatric liaison team.

7.   Conclusions made by [the] DHB following internal review

Their recommendations were to communicate deficits in the alert system to the project group on the electronic information system to communicate to the information manager weakness in the NHI duplication potential (this patient had two NHI numbers which raises the potential for communication difficulties and loss of information). They recommended reviewing with Planning and Funding the need for more locked rehabilitation beds in [the city].

I would have to agree with all of these recommendations. It sounds as if the first two are in the process of being solved.

8.   Locked Rehabilitation Units

My experience as a consultant psychiatrist has been principally in forensic psychiatry so I am familiar with security and locked wards. There is a sad paradox in the treatment of many patients with severe mental illness, schizophrenia especially, when complicated by the factors evident in this case. Had [Mr A] committed a more serious offence in November 2002 he would have been admitted to [a secure unit] for a longer period, and subsequently managed through their long term locked rehabilitation wards and possibly received more intensive follow-up if he were thought to impose a continuing risk to others. Many patients fall into the group of which [Mr A] is an example; that is they don't pose such a risk to the public that more coercive measures are considered essential.

I would have to agree with [Dr D] that it should have been evident after the January/February admission that community care was not working and a new approach should have been entertained. Medium to long term care in locked rehabilitation units is possible in some areas of New Zealand, though locked units are rare, and I am familiar with the [two units] mentioned in his report. While entry into [the low security unit] may have been ideal, but not achievable, I am inclined to agree that a medium-term placement in a locked unit could have been canvassed during his admission with consultation with staff from [the low security unit]. I also agree that the consultation liaison service should have had adequate time to contact [Mr A's] usual treatment team even if they didn't need to take much part in his assessment themselves. All it would have taken was a phone call.

I visited [the low security unit] in 2003 and understand many of their residents are former forensic patients. This unit is locked and seems to function very well.

It might be that [the city] needs another one or two of these. The [DHB] serious incident review panel in commenting on the option of long term locked unit care for this man outlines some advantages and disadvantages. I think that there are patients who can benefit from three to six months or more in such a unit and until it has been tried, you don't know that it is ineffective and until this has been tried, not everything has been done. Clearly the forensic psychiatrists do this, sometimes for years, and believe it works.

Treatment Options:

A lengthy period free from alcohol and drugs and with certainty of medication adherence would give the team a good picture of existing symptom levels and overall functioning. The point was made in the [DHB] report that treating his illness with long acting injections would be 'problematic'. I would argue that if this were to be commenced and monitored during a three to six month inpatient stay and there was a significant improvement in overall mental state then this itself may greatly enhance subsequent adherence to follow-up and acceptance of medication. Many patients threaten to abscond if injections are mooted but usually don't.

I also think the anti-psychotic drug Clozapine was a real option, notwithstanding [Mr A's] resistance to taking this drug. Clozapine often assists in reducing drug-craving; provides better control of psychotic symptoms, and the frequent blood-testing is in many patients, a positive aspect, not a 'nuisance', as it means more frequent contact with service staff.

A final point I could make is that of continuity of care. The most important in which continuity matters is that of information and after that continuity of care givers, especially case managers and psychiatrist. The organisation of services and changing staff are realities of psychiatric care and make the management of patients such as [Mr A] more difficult. As is usual in large DHBs, his care on leaving [the acute mental health unit] was transferred to a new psychiatrist and case-manager.

The final discharge summary in no way encapsulated the major difficulties and complexities presented by this patient.

In conclusion I would judge that this man's care fell below an acceptable standard in certain respects but these errors were essentially systemic and were about resources in part, but individual decisions by a number of clinicians and teams from 2003-2005 were also questionable.

Insufficient consideration appears to have been given to the likelihood that [Mr A] was more unwell than he appeared and his poly-substance habit meant his adherence to drugs for either his Addison's disease or Schizophrenia was very unlikely to be adequate and that his life would thus be put at risk from his Addison's disease, predation from other persons, drug overdose, or suicide.

I also wish to add that the last treatment teams merely continued with the plans of those teams who preceded them, as is so often the case, and cannot be reasonably held specifically accountable if their predecessors aren't. A completely new look at the case was desirable but did not occur. A formal request for a second opinion on his overall psychiatric management was indicated but not sought during his Jan/Feb 2005 admission.

The report prepared by [Dr D] in February was designed for a limited purpose; did he meet criteria for the Mental Health Act?

Limitations on Opinion:

My opinion as expressed in this report does have limitations. None of the documents I read described in detail the discussions and debate which may have occurred, and it may be that some of the omissions on which I comment were dealt with in this way. I was not asked to interview any of the involved clinicians, or family, which in the normal course of an adverse event review, I would, and information obtained from interviews may have modified some of my conclusions.

[Mr A] must have been a very worrying and frustrating patient for his family and treatment teams over the five years of his involvement with mental health services in [both cities].

On reading his history I find it something of a miracle that he survived five years with this constellation of medical and psychiatric disorders.

Peter Miller

Consultant Psychiatrist and Clinical Director

Psychiatric Rehabilitation and Intellectual Disability Services

Canterbury District Health Board"

 

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[1] Addison's disease is a deficiency in steroids produced by the adrenal glands. Ongoing medical treatment is required to manage this disease (replacement steroids must be taken daily, and ongoing missed doses can result in serious collapse or death).

[2] Hashimoto's disease affects the thyroid gland, resulting in decreased function requiring ongoing medical treatment.

[3] Section 29(3)(a) of the Mental Health (Compulsory Assessment and Treatment) Act 1992.

[4] Section 30(2) of the Mental Health (Compulsory Assessment and Treatment) Act 1992.

[5] The DHB advised that at the time it was not practice to keep the print-out of these clinical observations. However, practice has changed, and the print-out is now retained in the clinical records.

[6] In a letter to the Coroner dated 29 November 2005 the Clinical Leader, DHB Mental Health Services, advised that Mr A discharged himself.

[7] National health index.

[8] See 05HDC11908 (22 March 2007).

[9] Commissioner's note: Mr A was discharged, and did not discharge himself. He left the ward after the ward round at 10.20am, without his discharge papers.

[10] Commissioner's note: Dr D provided a report following his assessment on 27 January (see extract on page 3); this is described in the clinical record as a "second opinion".