The report does not reveal the hospital or facility he attended or the dates, or the names of those involved. The DHB's area includes the Tauranga and Whakatāne hospitals.
After he was discharged, the man was seen regularly by a psychologist from the DHB, and his care was discussed at multidisciplinary team meetings. However, he was not seen in person by a DHB psychiatrist, either during his admission or after discharge.
Tragically, he died the following year. His father complained to the commissioner about the services provided to his late son by the DHB's mental health service.
"There was a striking lack of psychiatrist input into the man's care, and the processes of
discharging and transferring the man from the various parts of BOPDHB's mental health
service were extremely poor," Allan said.
Allan was critical that the man was not seen by a consultant psychiatrist during his hospital admission, and not given the opportunity to meet with a psychiatrist when he continued to be unwell.
The multidisciplinary team did not play an effective role in optimising the man's
care, and the man did not have a case manager separate from his BOPDHB psychologist.
BOPDHB's failure to formulate and communicate a written plan with the man for his discharge from the community mental health service, and to communicate this to his family, GP and private psychologist, was also criticised.
Allan recommended that the DHB provide feedback on the implementation of the
recommendations made in its serious incident review; and consider introducing a procedural requirement for community mental health service clients to be seen by a psychiatrist every three months.
He also recommended that BOPDHB review its processes for discharging clients from the
community mental health service to ensure that a clear and comprehensive plan is
established; and that BOPDHB and the consultant psychiatrist provide a written apology to
the man's family.
Kevin Allan is the former mental health commissioner. This role was transferred to the new Mental Health and Wellbeing Commission in February 2021. However, HDC retains its
complaints resolution role in relation to mental health and addiction services.
Asked for comment on the report, BOP DHB chief executive Pete Chandler said the recommendations were being implemented.
"No family should lose a loved one in this way. This was a tragic case and our thoughts are with them.
"I have formally apologised to the family on behalf of the DHB and would like to take this opportunity once more to extend our sincere apologies and deep regret for our failings in this case and the distress it has caused.
"The recommendations made by the Commissioner in the report into this case are being implemented.
"We will continue this work to improve mental health and addiction services for the Bay of Plenty community and to ensure that local services meet national best practice standards," Chandler said.
WHERE TO GET HELP
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111
