Suicide ruling: woman died awaiting ‘urgent evaluation’ from DHB

WARNING: PAIN CONTENT

A woman in her 30s who struggled with major mental health problems took her own life while waiting for an “urgent evaluation” from the District Board of Health.

DHB and a RN today violated the Health and Disability Services Consumer Rights Code (the Code) for failures in mental health care for women suffering from depression and suicidal thoughts.

The decision of the Health and Disability Commission (HDC) comes about three years after the tragic death of the woman. The names and specific details of this case have not been reported for privacy reasons.

The investigation found that the woman’s GP had telephoned DHB and had spoken to a nurse requesting an urgent evaluation. They had discussed the woman’s depression and that she was feeling suicidal.

“Her mood has worsened, she no longer enjoys things; tearful and depressed most of the time. She spends most of the day in bed, doesn’t really sleep and sleeps badly at night. She uses alcohol and gets drunk. most nights a week to cope, “documented the GP at the time of the phone call, which was included in the HDC report.

The GP requested that the woman be seen by a mental health specialist at DHB that same day, but the evaluation was delayed and she died by suicide before it was carried out, according to the report.

Mental Health Commissioner Kevin Allan said the DHB had “seriously inadequate” systems and processes at the time of the woman’s referral.

In particular, there was no formal process to classify referrals, and electronic referrals were administered by administrators without a physician review for up to 24 hours, Allan said.

He said doctors also couldn’t easily access patients’ medical records and had to handle crisis calls in addition to their usual case load.

“DHB is responsible for the services it provides and must ensure that adequate systems are in place to help physicians perform their duties,” said Allan.

It considered that inadequate systems and processes “contributed to the low level of care provided in this case, with the result that opportunities to assess [the woman] with the urgency required they were lost. “

Allan recommended that DHB update HDC in:

• Your newly developed Mental Health Crisis Service Manual.

• Conduct an audit of the current process for managing incoming mental health referrals.

• Provide evidence of case reviews conducted for Mental Health Service physicians and report on the effectiveness of those reviews.

The Deputy Commissioner for Health and Disability also advised DHB to provide a written apology to the woman’s family, which has since been provided.

The patient’s family said in the report that they believed their loved one’s death was due to systemic failures and “multiple actions by many people over time,” and that in these circumstances she “would not want to be blamed. an individual for his death. “

They said they are grateful for the efforts and service improvements implemented in the wake of his loss.

The DHB accepted that systemic changes were necessary and noted that they have since been implemented.

The nurse said: “This incident has stuck with me and affected me personally and professionally. I have done considerable work since this time to improve my practice and have also continued to take steps to limit situations in which I feel stressed and overwhelmed.”

Where to get help:

• Life line: 0800 543 354 (available 24 hours a day, 7 days a week)
• Suicide Crisis Helpline: 0508 828 865 (0508 SUPPORT) (available 24 hours a day, 7 days a week)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24 hours a day, 7 days a week)
• Whatsup: 0800 942 8787 (from 13:00 to 23:00)
• Helpline for depression: 0800 111 757 (available 24 hours a day, 7 days a week)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737

If it is an emergency and you feel that you or someone else is at risk, call 111.