'Gaps in care' exposed by woman's death
A woman released from a mental health unit who drowned in the Pelorus River a week later had "fallen through the gaps" in mental health care, says a coroner.
Coroner Ian Smith questioned the care offered older patients by the Nelson Marlborough District Health Board's mental health services during an inquest into the death of Jasmin Gotty, 24, who drowned last year were released.
Miss Gotty's body was found in the Pelorus River shortly after 2pm on May 1 last year.
The hearing in the Nelson District Court heard that Jasmin Gotty had an extensive mental health history. She was diagnosed with psychosis, post traumatic stress disorder, borderline personality traits, substance abuse and had an intellectual disability.
The clinical director of Nelson Marlborough Mental Health Services Dr Mary McPherson said she was first referred to the mental health service in December 2008 after a suicide attempt.
She said she had been in and out of the mental health admission unit (MHAU) up until her death.
On Christmas Day 2012 she was re-admitted under the Mental Health Act and was tested for an intellectual disability. She had escalating inappropriate sexual behaviour, was hearing voices and was suicidal.
A nurse's report in April said she was vulnerable, sexually uninhibited, impulsive and difficult to contain in an open unit.
In April it was deemed she was a greater risk to other patients in the ward than she would be in the community so she was discharged. There were plans in place to put her in Franklin Village, but her mother Vonita Gotty said she had a letter from a lawyer allowing her to take Jasmin into her care.
Dr McPherson said Jasmin's continued placement in the MHAU was inappropriate due to an absence of current signs of mental illness, and because her sexually predatory behaviour was a risk to other patients.
She said the staff were not surprised at the possibility of Jasmin removing her clothing and swimming as "she went swimming as a self-soothing behaviour when distressed".
In a statement, Detective Senior Sargent Wayne McCoy said Jasmin, her mother and brother were travelling back from a day out in Picton when Jasmin got upset when her mother did not stop at the Trout Hotel pub.
She pulled over near Pelorus and Jasmin left the car in an agitated state. Ms Gotty drove off and returned 10 minutes later, but could not find her daughter. She thought she had found a ride back to Nelson, but after she could not find her there she went back to Pelorus and found her daughter's top and shoes by the river at Totara Flat.
The next day a search and rescue team found her body at the edge of the Pelorus River, near rapids.
In her statement, Vonita Gotty said after her daughter's release from the unit they were "sticking close together, she had to be watched night and day, even slept with me".
She would take her to the beach up to three times a day, as her daughter loved the water.
On the day she went missing, they had spent the day together in Nelson, then went to Cable Bay, and Picton.
Jasmin bought vodka, which Ms Gotty later smashed when her daughter was not looking. However, Jasmin had set some aside, which she continued to drink.
Her mother said Jasmin's combination of medication and alcohol made her tipsy quickly.
Coroner Ian Smith said it seemed Jasmin had "fallen through the gaps" in dealing with older patients with mental health and substance abuse issues. He said there was nowhere for an older person who was diagnosed with issues after 18 to be assisted as the NMDHB preferred patients to be living in the community rather that in units.
"The concept is good, but there are gaps we need to address," he said.
While Dr McPherson said she agreed and found it "‘very frustrating to have to discharge into circumstances that are not ideal."
He was concerned a letter from Jasmin's lawyer was not sighted by mental health service staff and was also concerned about the alcohol and drug issues spoken about in the statements.
Mr Smith said mental health, disability and alcohol and drug services within the NMDHB were too "fragmented".
His findings will be released later this year.
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