Mental health unit staff failed to check on suicidal patient for hours, found him in room after suspected suicide

Warning: This article discusses suicide.

Staff at a mental health unit failed to check on a patient at high risk of suicide for three hours, a report has found, in which time he's believed to have attempted suicide before dying of his injuries a few days later.

Mental Health Commissioner Kevin Allan released a report into the incident on Monday, finding the West Coast DHB in breach of the Code of Health and Disability Services Consumers' Rights for failures in its care for the man.

The patient - a man in his 60s who'd had a history of mental illness - was admitted to a mental health inpatient unit on the West Coast for diagnosis in 2018, after suffering worsening symptoms.

He was considered to be at moderate to high risk of suicide - but after being monitored over the course of the weekend, no new concerns had been noted, Allan reported.

That changed on Sunday night, however, when he "became agitated and refused his medication".

"During the night, he barricaded himself in his room and began slamming the door repeatedly. He expressed a desire to leave the inpatient unit, and rang his sister and a friend for support," a press release from the Health and Disability Commissioner reads.

"Nursing staff undertook visual observations of the man during the night, but from 6:30am to 9:30am on Monday morning, no visual observations of the man were undertaken."

It was at this time - during which a meeting was held to discuss the patient's health and his sister's concerns were conveyed to staff - that he is suspected to have attempted suicide.

Staff found him in his room at 9:30am after the attempt, and he died four days later.

In his review of the incident, the Mental Health Commissioner said the DHB failed to:

  • Transcribe possible diagnoses onto the man's admission form accurately
  • Fully document a medical plan for care
  • Document a nursing plan
  • Ensure that the man's room was checked for risk points
  • Complete hourly observations after 6:30am
  • Escalate the man's care when his condition deteriorated
  • Put in place appropriate policies for observations and escalation of care

Allan made several recommendations following the review, including the creation of an escalation policy, better staff training, and assessments of worker compliance, communication and teamwork skills within the team.

He also recommended the DHB conduct a review of risk assessments and audit the efficacy of new handover and admission forms, to ensure relevant information was being captured.

In a statement to Newshub, acting West Coast DHB chief executive Andrew Brant said it had apologised to the family of the man, and accepted all Allan's findings and recommendations.

"We would again like to reiterate our condolences to the person's family/whānau and friends, and express our sincere apologies for the fact he died while in our care," Brant said.

"We acknowledge that in 2018 a number of our systems and processes were not up to the required standards and did not support staff to provide the very best care.

"West Coast DHB has implemented a number of recommendations identified in the HDC report… These changes have enabled better continuity of care for patients, improved transfer of handover and admission information, and ensured staff are well supported through stronger teamwork."

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