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Coroner's findings following inquest into the death of Nicky Stevens

Fuseworks Media
Fuseworks Media

We have yesterday afternoon received the Coroner’s report following the inquest into the death of Nicky Stevens.

The death of Nicky was a terrible tragedy and this has been a long and painful journey for everyone involved, both the family, our staff and the wider community. I want to express my sincere sympathy to Nicky’s family for their loss.

We will now be working through the findings and recommendations in the report.

Since Nicky’s death we have made a number of changes including:

A stronger emphasis on involving whānau in their loved one’s care pathway, in recovery planning and discharge planning meetings and input into leave reviews. All staff now receive training on whānau inclusive practice.

Significant changes to our processes for escorted and unescorted leave in the inpatient wards at Henry Rongomau Bennett Centre (HRBC). There is now a three step process which requires agreement of the treating team, consideration of the doctor reviewing the patient and final approval by the consultant.

All leave is now subject to a formal Leave Authorisation and Management Plan which is part of the electronic clinical record and requires electronic signature by the consultant and review by the primary nurse. This includes clear definitions for the level of risk, the objectives and conditions of the leave and must be completed in agreement with the service user, multi-disciplinary team and whānau where possible.

The service user’s designated nurse is responsible for making sure the service user returns on time and if they are not back at the agreed time, a very clear process must be followed.

All new staff receive orientation to this procedure and existing staff have all received training on the revised procedure which was introduced in June 2015 and we audit to ensure compliance.

In April 2015 the ward configuration changed based on levels of acuity. Now the inpatient area has one ward which is more secure, inclusive of a perimeter fence with a separate open ward.

Changes to the entry and exit arrangements into HRBC mean that all visitors now enter through the front reception area with a system to record who has entered and exited the building.

The Ministry of Health also conducted a Section 99 inspection in 2016 which identified a number of recommendations which we have complied with, including additional staffing and greater community engagement.

It also identified that the HRBC inpatient unit on the Waikato Hospital campus is not fit for purpose and last week the Board approved the draft business case which we are taking to the Treasury for funding to build a replacement which will be designed with community, consumers and whānau.

We have also been looking at how we can improve our services with our ‘Creating our Futures’ programme. This has involved the voices of many of our clients and their whānau in how we deliver mental health services in the future, in particular on how we can do things differently.

With the release this week of the mental health inquiry report we look forward to the continuing importance and focus placed on mental health services in New Zealand.

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