Review slams DHB's mental health service

A litany of systemic failings have been uncovered by an investigation into the mental-health service at Palmerston North Hospital following two apparent suicides within three weeks of each other.

The MidCentral District Health Board commissioned an external review of the service after what it described as "two apparently self-inflicted deaths" of a similar nature in April and May raised concerns about underlying problems within the service.

A draft report of the external review obtained by the Manawatu Standard identifies several issues at the mental-health unit, including a passive, complacent culture, a lack of leadership, a lack of clarity in processes, a confusing service structure and inadequate facilities.

The reviewers also expressed concern over quality and safety processes relating to the two recent deaths, as well as subsequent "copycat" behaviour.

The review team was made aware "there had been further incidents involving [self-harm] on the ward during the weeks immediately following the two deaths, one of which had resulted in the patient involved being admitted to the intensive care unit".

"It was not clear that there had been a systematic and urgent attempt to learn from these or previous incidents in any specific way, or to increase the clinical expertise of staff . . . in order to prevent recurrences," the report said.

It was important the possible links between the two incidents and subsequent similar incidents were explored, it said.

"It is not clear that routine investigations of community deaths and ‘near-miss' incidents are sufficiently rigorous."

It was suggested to reviewers that patients with alcohol and other drug-use disorders were seen as troublesome and not as worthy of care as other patients, the report said.

The review team's overall impression was of a "passive, complacent and powerless culture" and, although there were clear policies on Ward 21, there was "apparently a lack of consequences for not following policies so they are seen as optional".

The service had unclear lines of reporting and accountability, decision-making was concentrated in an unbalanced hierarchy and financial considerations were seen by staff as barriers to change, the report said.

"We received no clear answer about who or which group was primarily responsible for managing and leading mental-health and addiction services."

Poor clinical governance and a poor sense of being part of a whole system was evident in every team, it said.

The adult inpatient unit would not meet standards for acute mental-health units in New Zealand and Australia, the report said.

"The first observation upon entering the unit is of a ward that is not set up with the needs of mental-health services users, family and staff in mind. The unit appears sterile and overly ‘clinical'.

The unit was not conducive to the type of recovery environment people needed to heal in, the report said.

District health board chief medical officer Kenneth Clark told the Standard that, while the report was yet to be finalised, the DHB accepted "the broad aspects of what we've seen of the draft report".

"We accept that there are matters within the service that require improvement and that we can have an even safer and better mental-health service in this DHB . . . we do have a very sound and robust set of mental-health services, our people can have faith in those services, but can they improve? We feel sure they can and we're going to be doing all we can to ensure those improvements [happen]."

Several actions had been taken to ensure ongoing care within the ward was safe for patients, Clark said.

"This has included the secondment of an experienced and skilled senior clinical manager to the ward, a review of all high-risk patients, an after-hours support plan, and a review of staffing mix and levels."

Clark said the DHB wanted to wait for the report to be finalised before making any further comments on likely changes.

"We will be forming our actions, there will be things that we wish to do and change and develop in the service," he said.

"We have engaged extremely senior high-quality individuals to do this review and we are taking their recommendations advice extremely seriously."


Key findings in the MidCentral Health mental-health services review: Governance processes and responsibilities lack clarity Service structure is confusing, with role duplications and mixed reporting lines A passive, complacent culture, which impedes learning, innovation and quality A deficiency in clinical leadership roles and skills Specific design problems in the ward facilities and environment 

Manawatu Standard