DHB breached standards, says commissioner
The care of a 45-year-old man with a severe personality disorder was below standard due to a string of breaches by his psychiatrist and the Bay of Plenty District Health Board, the Health and Disability Commissioner has found.
In his decision released today, Commissioner Anthony Hill said there was inadequate communication between care professionals and poor record keeping at the DHB's Community Mental Health service over a period of four months in 2010 until the man's suicide.
The man, who had bipolar disorder, tried to self-harm for the second time during a psychiatric assessment that same year, and was admitted to the Intensive Care Unit.
He was discharged two days later by a psychologist and was sent to his partner's home without CMH follow-up.
Three weeks later, the man was seen by a psychiatrist and a CMH nurse. But the assessment could not be completed, and it was rescheduled for a month later because the doctor was going on leave.
There were no plans for treatment during the psychiatrist's time away, but a crisis plan for the man was made with the CMH nurse being the first point of contact.
The psychiatrist placed his handwritten notes on the man's paper file, but did not communicate with the man's GP or partner.
The commissioner found the doctor also failed to document the man's crisis plan.
The man began having trouble within two weeks of the assessment, and his partner went to the Psychiatric Acute Community Team (PACT) three times over three days.
She had concerns about his behaviour and threats of suicide, however PACT did not access his paper file and the team was unaware there was a crisis plan in place, the commissioner found.
Despite recognising that the man's relationship breakdown and eviction were risk factors, PACT did not arrange to assess the man.
He was found dead from suicide a few days later.
Hill said the psychiatrist breached the Code of Health and Disability Services Consumers' Rights because his handwritten notes of the assessment were inadequate.
The psychiatrist also failed to communicate with the man's GP and partner, and did not take adequate steps to make sure that the crisis plan was documented.
Hill found the Bay of Plenty DHB breached the code because its CMH service failed to assess the man when his partner expressed concern, and didn't take the appropriate steps to involve her in the discharge planning.
The flow of information and communication between CMH, PACT and the GP was also not up to standard, Hill said.
Hill gave four recommendations, including having the DHB review CMH's referrals handling process and provide a written apology to the man's partner.
He also asked the psychiatrist to apologise and to undertake training on the DHB documentation standards protocol.