Now, the Health and Disability Commissioner has found two psychiatric workers in breach of their obligations, and fault in the police who did a limited handover.
“I wish to acknowledge the impact of these tragic events on everyone involved, including the psychiatric social workers. A death in these circumstances no doubt continues to have a deep impact on those individuals long after the event,” Deputy Health and Disability Commissioner Deborah James said a decision released today.
Mr A was under the care of Health NZ Māori mental health and had a diagnosis of paranoid schizophrenia and a history of alcohol and drug abuse.
According to James’ decision, in the months leading up to the incident, he had become violent towards his wife, was experiencing breakthrough psychotic symptoms and was prescribed an increase in his paliperidone injections.
On the day of the incident, the family was under stress from moving house and Mr A threatened self-harm.
His wife called their support worker and during that intervention, police were called and detained him under section 109 of the Mental Health Act for an assessment.
Two psychiatric social workers were called to the police station and told the commission that on that day, staffing was low and there were no medical practitioners available.
Ms B and Ms C both told the investigation hearing that when they arrived at the police station the reception was ‘not very warming’. They said a limited handover was done and no information was passed on that Mr A was being detained under the Mental Health Act.
Their notes recorded the reason for the assessment was because his wife raised concerns about risk to himself.
Neither of them contacted his wife for input or consulted a psychiatrist or any other clinician during their assessment. Since they were not qualified to administer his now three-day overdue paliperidone injection, they provided him with a safety plan, advising him to take olanzapine overnight and to avoid alcohol and drugs.
The safety plan was discussed with Mr A and they deemed him as a low risk to himself and drove him home.
His wife was surprised when her husband returned home as she was expecting him to be admitted to a hospital. By 5.30pm, he had died by suicide.
After his death, Health NZ conducted a serious adverse event review, identifying several shortcomings in the social worker’s care and assessment. His wife also complained to the Health and Disability Commissioner and an investigation was launched.
Independent advisers to the HDC, psychiatrist Dr Alma Rae and psychiatric social worker Nicole Begley, found the pair overlooked crucial information in their assessment, including his earlier threat to self-harm, the impact of Mr A’s recent substance abuse and an overreliance on his self-reporting.
Rae remarked it was “incomprehensible” a medical practitioner was not present, which, though the responsibility of the police, should have prompted the social workers to consult a psychiatrist to discuss their findings.
“While I accept that the police handover may not have been as thorough as ideally it could have been, this does not absolve the psychiatric social workers of the obligation to seek information as to why Mr A was being held at the police station or to consult with others to obtain the necessary information upon which to base the assessment,” James said in her decision.
When Mr A refused respite care, Rae found the social workers resorted to a lower level of care to send him home, which was “misguided, unsafe and inappropriate”.
“The power dynamics at play when she [his wife] found two mental health professionals and her abusive husband on the doorstep could hardly have disadvantaged her more. It would be a very unusual woman in such circumstances who could or would turn her husband away, however much she wanted to. Mental health professionals are supposed to know these things and behave accordingly,” Rae said.
Both social workers were found in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights and Health NZ was criticised for not ensuring adequate training for its staff and deficiencies in its training policies.
Health NZ acknowledged the training for psychiatric social workers was inadequate and there were gaps in the training records for both Ms B and Ms C.
They have since extensively amended their policies and ensured medical officers are available full-time in the region as well as access to support for their staff after hours.
Both practitioners have since undergone extensive training and met with Mr A’s whānau in 2019 to formally apologise.
“The emotional impact for [Mr A’s] wife’s and his whānau’s ongoing grief and loss has continued to remain with me. My reflection of this process was to acknowledge the passing of [Mr A] and the whānau collective voice to ensure that his death is honoured and the learning and subsequent changes are used as [a] guide to my practice,” Ms C said.
As all parties have made several changes and improvements, the commissioner had no further recommendations.
Shannon Pitman is a Whangārei-based reporter for Open Justice, covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.
