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Cultural care plan and psychiatric review of at-risk patient - HDC

Fuseworks Media
Fuseworks Media

Mental Health Commissioner Kevin Allan today released a report finding Southern District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide services to a woman with reasonable care and skill.

Mr Allan found that the DHB did not have an adequate care plan in place for the woman, which was contributed to by a lack of psychiatric review over a protracted time. This issue was compounded by the absence of a cultural care plan, and the lack of elementary factors of Māori communicaton and care in the DHB’s engagement with the woman.

The woman had been a consumer of mental health services since the 1990s. In 2015 her mother contacted the DHB’s mental health emergency team (MHET) with concerns about her daughter’s mental health. A psychiatrist assessed the woman as not requiring hospital admission, concluding instead that she could be managed by the community mental health team.

The following month the woman’s mother told MHET she had confiscated hunting knives that had been in her daughter’s possession. She also reported that her daughter’s highs and lows were more extreme. A short time later the woman was taken into Police custody after harming a woman unknown to her.

Mr Allan found the DHB breached Right 4(1) of the Code for failing to provide services to the woman with reasonable care and skill.

"This was a complex case with several mitigating factors. Overall, however, I am of the view that the failings exhibited are systems issues for which SDHB is accountable," Mr Allan said.

"This decision highlights the importance of having a broader overall care plan for any consumer, which will require timely psychiatric oversight and should always take account of cultural needs."

Mr Allan recommended that the DHB assess how it’s cultural and clinical care can be best co-ordinated and integrated, in collaboration with local Māori communities, and with input from consumer and family / whanau advisors. He acknowledged the work the DHB had already done in this regard and recommended that it provide a further update to HDC in relation to the changes made since this complaint, and in relation to the outstanding recommendations made following its own Serious Adverse Event Review.

The DHB provided letters of apology to the woman and her family.

The report for case 16HDC00195 is available on the HDC website.

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