The mental health service at the Middlemore Hospital campus in South Auckland has been faulted over the death of a patient.
Mental Health Commissioner Kevin Allan lists a series of failings and says the Counties Manukau District Health Board breached the code of patients' rights.
Among his recommendations, following an inquiry, he suggests the DHB consider having psychiatrists on duty at its acute mental health unit during weekends and public holidays.
In his report issued today, Allan says the police found a man wandering outside an airport. The case occurred in 2014. The man was aged in his 50s.
He appeared dazed and confused and was taken to a police station, where he was seen by a specialist psychiatrist and a social worker.
The psychiatrist considered the man was suffering from psychosis, possibly drug-induced or associated with a mood disorder. The man was admitted to a psychiatric inpatient unit.
A second psychiatrist considered the man was mentally disordered and formally notified him of compulsory assessment and treatment under mental health legislation.
The man was reviewed by a specialist psychiatrist, who planned for further assessment and monitoring for signs of withdrawal. She recorded a request that the man be reviewed by a registrar (a specialist in training) the following day, a Saturday and on the Sunday if necessary. However, the man was not reviewed again by a psychiatrist during his admission.
Later that day, a house officer (a junior doctor) made a physical examination, recording a history of substance abuse, chronic pain, and anxiety, but making no risk assessment.
On the Saturday the man's mood appeared low, and he was subdued and kept to himself. There were no signs of withdrawal. The house officer reviewed him again but did not request a review by the on-call psychiatrist or undertake a risk assessment.
On the Sunday afternoon the man was visited by two friends. They expressed concerns about him to his nurse, and although these were recorded, a medical review was not sought.
Early on the Monday, a psychiatric assistant saw the man standing by his open door acting unusually. About two hours later he was found unconscious in his room and couldn't be resuscitated.
Allan said the DHB failed to provide reasonable care. Staff failed to arrange a psychiatric review of the man over the weekend and failed to monitor him for signs of withdrawal as required by the specialist psychiatrist's plan.
The man's risk was not assessed sufficiently following his admission and staff failed to respond adequately to his changing presentation. Staff also failed to respond adequately to the concerns raised by the man's friends.
Allan has urged the DHB:
• To give more staff training on patient risk assessment, and
• To consider having a specialist or registrar working at the inpatient unit at weekends and public holidays.
He also wants an update on the corrective action plan written by the DHB in response to the failings found in its care of the patient.
The DHB's acting chief executive, Dr Gloria Johnson, said it offered its sympathies to the man's family and had apologised
It had fully implemented the commissioner's recommendations.