[ad_1]
A highly agitated and suicidal mental health patient climbed onto the roof of a Christchurch psychiatric hospital and jumped, breaking both ankles.
The man, who was in his 30s at the time, was not taken to the emergency department (ED) for four and a half hours.
Mental Health Commissioner Kevin Allan discovered that the Canterbury District Health Board (CDHB) failed to properly observe the man and took him to the emergency room after the incident.
“The mental hospital staff should have given more weight to the warning signs of Mr. B’s condition,” Allan said in a report released Monday.
READ MORE:
* The man died after lung injury was found, but the cancer was not treated.
* Doctors in the Christchurch cancer department, which are understaffed, are trained in stress management
* Shorter socks, paper cups and cheaper medications: Canterbury health authorities describe cost cuts
The man, referred to as “Mr. B ”in the report, had a history of severe depression and was admitted to a psychiatric hospital on August 22, 2017, after his mood deteriorated significantly and he had suicidal thoughts.
He suffered from complications from type 1 diabetes, including a previous skin graft from an ulcer, and clinical notes said he had given up on controlling his diabetes.
David Walker / Stuff
A report from the Commissioner of Mental Health found that the Canterbury DHB violated the Consumer Rights Code for Health and Disability Services when a mental health patient jumped from the roof of a psychiatric hospital.
Six days after being admitted, the man’s risk of suicide and self-harm rose from moderate to high after he told staff that he believed he would die from diabetes-related complications within a year and wanted to die.
On August 29, he left the open ward and was found in the middle of the street near the hospital. He told staff that he was looking for a tall building to jump into.
During an overnight visit with his family, he told his wife that he was experiencing suicidal ideation and that he had a plan to harm himself and others.
The man was placed under section 11 of the Mental Health Act, which makes treatment mandatory, and was transferred to a secure area of the hospital.
On the morning of September 4, the man was seen stacking chairs on the patio in an attempt to climb the fence.
He felt distressed in the afternoon after being told that a relative had been taken to the emergency department for an X-ray. He asked to go to the emergency department to be with them, but his request was rejected and he became very agitated and verbally abusive.
A registered nurse and a health assistant were unable to calm down and the nurse called staff in the main ward to discuss the situation.
The health care assistant watched the man enter the courtyard to smoke a cigarette around 4.25pm
About five minutes later, the man had wedged a chair into the fence and climbed onto the roof of the hospital.
The two staff members saw him jump the 2.5 meters from the roof onto the lawn next to the building.
Mr. B could not move without severe pain and they found a wheelchair to take him to the room where he was administered codeine.
The staff decided to keep him in the psychiatric hospital until his family was no longer in the emergency department, as they were concerned about the man’s suicidal ideation and “auditory hallucinations that indicated he was harming his family.”
His ankles were treated with elevation, ice, and compression in the psychiatric hospital.
The man was taken to the emergency department in a taxi, accompanied by a registered nurse, around 9:15 p.m.
Allan’s and the independent expert’s opinion criticized the way CDHB staff viewed the man.
The man shouldn’t have been alone in the yard, not even for the brief time it took him to make a phone call, Allan said.
“The mental hospital staff should have given more weight to the warning signs of Mr. B’s condition.”
The man should have been transported to the emergency department as soon as possible, where staff could have managed the risks he presented to members of his family.
The commissioner recommended to the CDHB that they apologize to the man, review his observation policy and documentation of observation activity.
CDHB Medical Director Sue Nightingale said she had apologized to the man “for the poor level of care provided by Canterbury DHB.”
“We would like to assure the public that we have made improvements to our systems and processes to reduce the chances of an incident like this happening again.”
