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The model of care provided by an Auckland mental health unit has come under fire after the deaths of four patients.
The Waitematā District Board of Health commissioned an external review after two suicides at its facility, He Puna Waiora, in the same week in 2019.
Since then, DHB has taken steps to upgrade the 35-bed inpatient facility at Takapuna on the North Shore.
On May 12, 2019, a hospitalized patient, known only as NB, was found dead in the unit.
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Just five days later, another hospitalized patient, Tamaki Heke, 24, was also found dead.
There had also been two other patient deaths while under the care of Waitematā DHB.
Supplied
Tamaki Heke was one of the hospitalized patients who died in May 2019.
Through interviews with patients’ families and DHB staff, the report, prepared by Alison Masters, Malcolm Steward, Sarah Gordon, Stu Bigwood and Jason Cabral-Tarry, found several problems with the unit.
These included problems with leadership and culture, the model of care provided, and problems with nursing care and staff deployment.
The design of the building was also found to be problematic.
The report’s writers found the leadership to be “poor and inadequate” at the time of the deaths.
This finding was obtained by interviewing the personnel and relatives of the deceased, who spoke of problems at the clinical, unit and DHB level.
“The clinical leadership and organization within He Puna Waiora was described by a variety of staff as improving, but possibly not yet fit for purpose,” the report says.
“Concerns included frequent difficulties for clinical staff in obtaining support for supervising senior staff in resolving difficulties, ineffective leadership, and difficulty in obtaining support in accessing resources to respond to individual needs.”
The way in which care was delivered was also considered inadequate to meet the demands for care at the time of deaths.
The lack of understanding of the high and complex needs of the people entering the unit was found to be a limitation.
The nursing model was also found to be a problem, as staffing shortages meant that nurses were frequently switched from one group to another, leading to inconsistencies that affected relationships with families and the care patients received. .
“The family and the whānau described that it was difficult to find personnel who knew or were responsible for the support of their family or member of the whānau when they became engaged to He Puna Waiora.”
The report said it was critical to ensure that patients and their families were able to establish a relationship with individual staff.
The design of the unit also turned out to be a problem. Despite being modern and well-maintained, the high-care area was considered crowded and suffered from a lack of “active de-escalation space”.
“There are quiet spaces, but the lack of an area where people can safely ventilate, both verbally and physically, is deeply felt.”
The report’s writers made a series of recommendations to the DHB, including strengthening leadership, focusing more on patients and their families, and improving the way care is delivered.
Waitematā DHB Director of Mental Health Derek Wright said the DHB expressed its condolences and apologies to the families of the patients who died.
“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 accepts the findings of the review and we will continue to implement them in full. Many of the recommendations have already been addressed during the last 18 months while the review was underway. Recommendations that have not yet been addressed will be addressed. We will continue until the entire content of the report has been implemented. “
“Although the report is conflicting in parts, we fully accept our duty to be responsible for our care, and note that He Puna Waiora is a different and safer unit today than it was in May 2019.”
