The Bay of Plenty District Health Board has been criticised for serious failings in the care it provided a mental health patient who later committed suicide.
The Health and Disability Commissioner found the board breached the code of health and disability services consumers' rights several times during a four-month treatment period of a patient who committed suicide in 2010.
The board also failed to meet national mental health sector standards.
The 45-year-old man, known as Mr A in the report, had been variously diagnosed with bipolar affective disorder, personality disorder with mixed features and cyclothymic disorder (a chronic mood disorder).
Mr A's partner, known as Ms B, approached the psychiatric acute community team at Tauranga Hospital concerned at his abusive behaviour and refusal to take medication, which forced her to move out of the house they were living in.
She was referred to her partner's GP but the team did not inform the doctor, known as Dr G.
A month later, the man attempted suicide and, while being treated at hospital afterward, was reluctant to engage with the community team and was discharged. There was no further attempt to conduct a full mental state assessment, the report found.
Four days after the man's suicide attempt he attended an outpatient assessment with a psychiatrist who diagnosed him as having a personality disorder with acute [stress] in coping and risk [in social stress].
During the assessment the man self-harmed and was admitted to the hospital's intensive care unit.
He was discharged two days later after an assessment by the consultation-liaison team psychologist, who found no acute mental illness and no acute risk as "the relationship issues with his partner [appeared] to have now resolved".
There was no communication made with the patient's partner.
Another doctor, Dr C, attempted a second assessment but was unable to complete it and made an interim crisis plan where a registered psychiatric nurse, Mr D, was to be the patient's point of contact for any concerns.
However, the psychiatric acute community team was unaware of this assessment or of Mr D's role.
Handwritten notes from the assessment were filed but did not document Mr D's role or the crisis plan.
Neither Dr G nor the man's partner was informed.
In the days that followed this assessment, the man's partner repeatedly approached the community team concerned about his behaviour and threats of suicide.
She was advised in steps to remove him from her home.
Although the patient's electronic record showed he had attended the second assessment two weeks before, the psychiatric acute community team overlooked this and did not access his paper file.
"The mental health services were aware that the relationship breakdown and imminent eviction of Mr A were significant risk factors for his self-harm, however no arrangement was made to review Mr A."
The man was found dead a few days later.
The commissioner recommended the board and Dr C write apologies to the man's partner for their breaches of the code.
The board was also instructed to review its operating procedures and policies, providing the commissioner with evidence of changes made.
The report found a "lack of clarity" around certain roles and failures in co-ordination between the mental health services that "impaired" Mr A's continuity of care.
"Bay of Plenty District Health Board missed opportunities to assess Mr A on at least two occasions ... when Ms B presented to the psychiatric acute community team with concerns about Mr A's mood, suicide threats and impending eviction," the report stated.
The board accepted the findings.
"We fully participated in the commission's process and are currently implementing the recommendations," board chief executive Phil Cammish said.
Independent specialist and consultant psychiatrist Dr Murray Patton said overall the care provided to Mr A was patchy and there appeared to be "reasonable oversight".
There were some aspects of the systems of care that appeared to have been deficient and contributed to the overall approach not being of a reasonable standard, Dr Patton said.