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123RF / Stuff
A woman was referred for an urgent mental health evaluation but was set aside for follow-up the next day. The next morning, she was dead. (File photo)
A woman committed suicide after an urgent mental health assessment was delayed, the health watchdog found.
The woman, in her 30s, had a history of depression, post-traumatic stress disorder and “significant” mental health problems.
Her GP referred her to DHB in 2017 for an urgent evaluation regarding concerns that she was having suicidal thoughts.
However, an evaluation was not carried out immediately. Instead, the reference was printed and placed on an office tray for discussion at a meeting the next day.
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Early the next morning, the woman’s GP learned that she had committed suicide.
A report released Monday by Deputy Commissioner for Health and Disability Kevin Allan criticized the district’s health board, which is not mentioned in the report, for its failures in caring for women.
“In my opinion, there was a severe deviation from the accepted standard of care in managing this referral,” he said.
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“The initial decision to reject an evaluation meant that there was no opportunity to identify and consider [the woman’s] clinical needs, medical history and risks “.
DHB had violated the Health and Disability Services Consumer Rights Code, Allan said.
It had “seriously inadequate systems”, in particular, no formal process for evaluating referrals, he said.
Doctors couldn’t easily access patients’ medical records and had to manage crisis calls in addition to their usual case load, Allan found.
There was a “poor level of care in this case” and “opportunities to assess [the woman] with the urgency required they were lost ”, he said.
Allan recommended that DHB undertake a number of improvements, including an audit of the current process for managing mental health referrals.
He also asked DHB to provide him with an update on their newly developed mental health crisis service manual.
He said the DHB had provided a written apology to the woman’s family and would also provide it to her GP.
Where to get help
- 1737, do you need to talk? Call toll free or text 1737 to speak with a trained counselor.
- Kidsline 0800 54 37 54 for people up to 18 years old. Open 24/7.
- Life line 0800 543 354
- Rural support trust 0800 787 254
- Samaritans 0800 726 666
- Suicide Crisis Helpline 0508 828865 (0508 SUPPORT)
- Youthline 0800 376 633, free text 234, email [email protected], or find online chat and other support options here.
- Anxiety New Zealand 0800 ANXIETY (0800 269 4389)
- If it’s an emergency Click here to find the number for your local crisis assessment team.
- In a life-threatening situation, call 111.
