A coroner has strongly criticised the Capital & Coast District Health Board for its inadequate treatment of a man who killed himself after being discharged from Wellington Hospital.
In a rare step Coroner Garry Evans relaxed restrictions around reporting of suicides in order that the public should confidence in the public health system and treatment of mental health problems.
Bryan John Eastwood, a 39-year-old father, was battling a severe drinking problem and had just separated from his wife when he died on March 15 last year.
Coroner Evans heard that about a month earlier he was arrested for driving drunk and resigned from his job as a result.
Two days later he went to his GP feeling "anxious and miserable" and was given anti-depressants and medication to help him with sleeping and alcohol withdrawal.
On March 13, Mr Eastwood went to Wellington Hospital's emergency department after overdosing on clonazepam and drinking up to 23 units of alcohol.
A risk assessment noted a number of concerning features including alcohol abuse, social isolation, the break-up of a significant relationship, the loss of his job and recent criminal proceedings.
Nonetheless, he was assessed as not wanting to die and, rather, the overdose was considered an attempt to get his wife's attention.
A nurse unsuccessfully tried to contact the on-duty registrar, but Coroner Evans said the telephonist may have been calling the wrong doctor.
The registrar was required to be contacted in such cases but Mr Eastwood was discharged anyway.
Nurses involved in the case commented that there was considerable pressure to discharge clients within six hours due to the hospital's "six-hour rule".
Several unsuccessful attempts were made to contact Mr Eastwood after he was discharged but he was found dead by his wife and father at his one-bedroom Khandallah flat.
Mr Eastwood's GP was not notified by the DHB until after his death.
Coroner Evans said he should not have been discharged until he was seen by the on-duty registrar and the DHB should have considered admitting him to its short-stay unit.
The DHB could not get in touch with Mr Eastwood after he was discharged, but Coroner Evans said they did not try hard enough and no attempt was made to contact his GP, wife or anyone else concerning his welfare.
Mr Eastwood's death prompted a DHB review. It resulted in several recommendations including a review of mental health assessment guidelines in the emergency department, and a recommendation that the short-stay unit be considered for intoxicated patients. These recommendations were endorsed by Coroner Evans.
The review team noted that Mr Eastwood's GP had been faxed when he was discharged but considered that a verbal handover should have occurred.
Alison Masters, the DHB's clinical director of mental health, addictions and intellectual disability directorate, said in a statement that since the incident a revised crisis assessment treatment team manual had been developed.
"This includes updates on developing written plans for suicidal patients presenting to the emergency department, as well as clear directions on communications with GPs following an incident."
The manual also clearly stated that the DHB's target of shorter stays in the ED should never override safe clinical decision making and actions.
The night time registrar handover process had also been been updated to ensure an alternative contact was in place if the registrar could not be reached, Dr Masters said..
The Ministry of Health Declined to comment, a spokesman saying it was a matter for the DHB.
Media are generally prohibited from reporting coroners' findings on suicides, but in this case Coroner Evans said making the case public would promote public safety.
"Where they [sic] may be inadequacies or deficiencies in the delivery of those services, it is desirable that the public should know that the reasons for such inadequacies or deficiencies have been inquired into and that steps have been taken with a view to ensuring they do not occur again."
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