Condemnatory review places DHB leadership after two alleged suicides in four days

A grieving adoptive parent says health chiefs didn’t ask key questions at a North Shore mental health unit where two patients died in suspected suicides just days apart.

A damning review on a series of sudden deaths at Waitematā DHB’s He Puna Wāiora has cited poor leadership and staff burnout and suggests that the physical design of the building helped patients take their own lives.

The review also found other critical flaws in He Puna Wāiora in Takapuna, meaning that patients felt neglect, humiliation, stress, and disrespect, resulting in some losing hope and ‘giving up’.

Waitematā DHB today apologized to the grieving families whose loved ones died in their care, admitting that their lives will never be the same again.

“We are deeply sorry and committed to getting better,” said Director of Mental Health Derek Wright.

Peter Willcox lost his adopted son Tamaki Heke in an alleged suicide in May of last year. The family warned staff that Heke was suicidal just hours before the 24-year-old was found dead in his room.

Heke’s friend is believed to have taken his own life in the unit just four days earlier.

Willcox told the Herald the report was grim reading.

It showed that the DHB board had let the unit “drift” for years without proper oversight.

“They weren’t asking key questions.”

He was pleased that the report did not attribute individual blame, as the problems were systemic and likely affected other units.

He appreciated the DHB’s apology, but said more than “well-intentioned words” were needed.

“They seem to be prepared to take it with the chin and do something. And that’s very satisfying as a victim of the system. Take it with the chin, learn from it and change.”

The DHB commissioned the independent review following two alleged suicides at the unit in the space of four days in May last year.

The review was published today after more than a year of research. It makes a series of recommendations to the DHB and the health sector in general in an attempt to prevent further unnecessary tragedies.

“The review panel recognizes that the unexpected death of a person that occurs during hospital admission is a tragic event that causes immense distress to families, caregivers and staff,” the report says.

“This is especially so when the person has died by suicide. We wish to extend our deepest condolences to the family and whānau of those whose deaths led to this report being commissioned.”

He Puna Wāiora is a 35-bed inpatient adult mental health unit adjacent to North Shore Hospital.

The review says that on May 12 last year “NB” was found dead in the room.

Heke died on May 16.

The external review was commissioned to examine the tragedies and the operation of the unit.

A draft report was also distributed to the families of two other Waitematā DHB mental health patients who died in suspected suicides.

The review was tasked with investigating:

• The physical security of the room, including “tie points” and possible solutions;

• Clinical governance and identification of any deficits;

• Culture and clinical care;

• Oversight of the mental health leadership team;

• Policies for communicating with families and responding to urgent concerns raised by whānau.

Lack of leadership

He found serious deficiencies in the unit’s leadership, which was labeled limited and incoherent, lacking in transparency, controlling, and “indifferent to the issues and opinions raised by front-line staff.”

The review found that the unit’s model of care “was not well articulated, focusing more on staff roles than how care is delivered … and reflecting a predominantly biomedical model of care.”

Patients and their families felt that staff were overly reliant on clients’ medications rather than treating their underlying problems, which often resulted in long stays or readmissions.

“There was stigmatization of long-stay people as ‘bed blockers.’

Families also felt there were “few” recovery programs or activities for patients, with activities such as the gym and sensory room often blocked and unavailable.

They said it would be helpful to “find a way to give people hope and fun.”

Families and patients also mentioned disrespectful or incompassionate treatment by staff. They felt their comments were often ignored, and viewed by staff as a “distraction and annoyance.”

“We consider that a consequence of these problems was feelings of hopelessness and helplessness for consumers, family and whānau and sometimes staff,” the review said.

The families told the review they felt left out of the previous investigations into the deaths. The lack of inclusion meant that the reports contained “factual inaccuracies”, causing them additional distress.

The review did not identify an effective primary nursing system in the unit and said there was ‘strong evidence of dysfunction’ across teams.

There was significant pressure on the beds due to high demand and bed closures due to staff shortages.

Some of the staff were “overwhelmed” and burned out.

The review said an audit of the physical building’s potential self-harm risks was completed prior to the two suicides, with additional work areas identified.

Completing that work was deemed critical to the safety of the unit.

Unit protocols now require a physician consultation before reducing the frequency of observations for at-risk patients and notifying the family of any changes.

The report said that inpatient suicide deaths were relatively rare, meaning that even experienced staff had little experience dealing with such tragedies.

“Suicidal contagion, in which the death by suicide or attempted suicide of one person is followed by suicidal behavior of others in the same community … is widely recognized and constitutes a significant risk in a mental health unit for hospitalized patients “.

Despite this risk, the review found that no document or protocol existed to guide staff after suicide.

The deaths that led to the review were “deeply regrettable.”

But the DHB had made considerable efforts to learn from the tragedies and take steps to reduce the risk of similar events.

“Unfortunately, there is no way to completely eliminate that risk, but strenuous efforts have been and are being made to reduce it.”

The review makes a series of recommendations on strengthening leadership and culture, clinical care, and a greater focus on families and individualized care.

“In particular, any concerns expressed by family and whānau about the safety of a consumer must be taken very seriously and responded to with appropriate clinical action.”

He also called for a broader review of specialty services for mental health inpatients to ensure they receive treatment for underlying conditions to avoid long stays in compulsory care.

My condolences

In a statement, DHB’s Wright said the review was commissioned by the DHB immediately after the deaths “to obtain independent information” on how the unit was operated.

He expressed the deepest condolences from DHB and apologized to the families.

“We thank them for their courage in assisting in the review and we also recognize that life will never be the same for them after the loss of their loved ones.

“We are deeply sorry and are committed to doing better.

“We cannot go back in time, but we can learn from the past and make changes that will minimize the potential for inpatient deaths in the future, while recognizing that it is impossible to eliminate all risks, as the report notes.”

DHB unconditionally accepted the findings of the review and committed to implementing them in full. Many had already been addressed.

“We welcome scrutiny and are proactively releasing the report because we believe that only the good will come from ‘letting the sunlight in.’ Puna Waiora is a different and safer unit today than it was in May 2019.”

Wright hoped that sharing the report with other mental health services across the country would help their continuous improvement work.

He said the unit staff were highly motivated to help and care for others, and they tried hard to do their best.

“We support our people to keep doing their job and we will continue to make the necessary changes to help them do it at the highest level possible.”

Where to get help:

• 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP) (available 24 hours a day, 7 days a week)
• https://www.lifeline.org.nz/services/suicide-crisis-helpline
• YOUTH LINE: 0800 376 633
• I NEED TO TALK? Toll Free or Text 1737 (Available 24/7)
• KIDSLINE: 0800 543 754 (available 24 hours a day, 7 days a week)
• WHATSUP: 0800 942 8787 (from 1:00 p.m. to 11:00 p.m.)
• DEPRESSION HELPLINE: 0800 111757 or TEXT 4202
• NATIONAL ANXIETY 24 HOUR HELP LINE: 0800 269 4389