Hutt Valley mental health service has come under fire again over the death of an intellectually disabled woman.

The health and disability commissioner highlighted several failures in the treatment the woman received over nine months in 2009 and 2010, including the inability of staff to detect mental health problems because of her disability.

The woman lived at home with her parents and frequently contacted emergency services threatening to kill herself because she wanted to move out.

She was assessed by the Crisis Assessment and Treatment Team several times, but it failed to refer her to experts in dealing with intellectually disabled people who also had mental health problems, the commissioner said.

Several agencies were involved in her case and the failure to share information compromised her care, commissioner Anthony Hill said.

In his view, the Hutt Valley District Health Board's failures to identify a lead provider, recognise and respond to the differing levels of expertise of its staff and ensure the woman was appropriately assessed, resulted in her not being provided with services with reasonable care and skill.

He concluded the health board breached the Code of Health and Disability Services Consumers' Rights.

"[She] was not provided with the level of care she required, because there was a general belief among the persons supporting her that her behaviour was caused by her intellectual impairment and unhappiness at having to live with her parents, rather than any mental health issues."

The chief executive of support group CCS Disability Action, David Matthew, said health professionals and agencies needed to "see the person rather than the disability". "The label got in the way for the right sort of help being provided for this person."

Mr Hill's written decision came after a damning report from an inquiry into treatment blunders and leadership problems within the mental health service at Hutt Valley DHB.

The inquiry painted a picture of an organisation that had broken down "at multiple levels", was understaffed, and in which managers were overworked.

It looked at the service in the two years from June 2008 and listed failings in the care of five patients.

The intellectually disabled woman was not one of the patients whose care was investigated in that inquiry, DHB chief executive Graham Dyer said. However, it was "entirely consistent" with the systemic problems at the time.

"It's 2½ years ago and I think it's systemic issues rather than individual negligence that we're talking about here."

The family received an apology and the board accepted the recommendations, which included signing a memorandum of understanding with Capital & Coast DHB on referring disabled people with mental health problems.

The Hutt Valley DHB said her death was not suspicious.

- © Fairfax NZ News