Auckland Hospital's ED was so busy in March that some patients were placed in an atrium designated as an overflow area for mass-casualty events. Photo / NZME
A mental health patient at Auckland Hospital was made to wait 94 hours in the emergency department because there were no beds available in the psychiatric unit, according to a damning internal email obtained by the Weekend Herald.
The nearly four-day delay was “the longest any patient, under ANY service, has ever waited for an inpatient bed in our department”, a senior emergency doctor told hospital executives in an email on March 29, soon after the person was finally admitted to the adult mental health ward.
“Anecdotally, it may be the longest ever stay for a MH [mental health] patient in any New Zealand ED,” the doctor said.
Two other acutely unwell patients were “marooned” in ED at the same time. They waited 58 and 65 hours to be admitted to Te Whetu Tawera, the 58-bed inpatient psychiatric facility, the email said.
The extraordinarily long waits caused enormous distress to the patients, disruption in the department and grave concern among staff. The doctor who wrote the email was so dismayed they alerted more than two dozen executives and senior clinicians and called for an urgent overhaul of how the ED manages patients with acute mental illness.
“The chaotic emergency department is a completely inappropriate environment to detain unwell MH patients for long periods of time,” the doctor said, “and yet the organisation does not seem to have developed any safe and appropriate alternatives other than continuing to increase pressure on [Te Whetu Tawera] to discharge patients.”
While the three people were stuck in the department, staff twice called a “Code Orange” – an emergency call for security backup – because of “agitation and self-harm” and a hospital employee was assaulted, the email said.
“In detaining these patients in ED for long periods of time we are undoubtedly in breach of multiple pieces of legislation on a multiple-times-weekly basis,” the doctor said, citing the Health & Disability Commissioner’s code of rights, health and safety laws, and “possibly the Crimes of Torture Act”.
The details in the doctor’s email were confirmed by another staff member with knowledge of the incidents and were not disputed by Te Whatu Ora Te Toka Tumai Auckland, the authority that runs the hospital.
Te Toka Tumai Auckland, which replaced the Auckland district health board last year, would not comment on specifics because of privacy considerations but it said the staff member who was assaulted was not injured and had been offered support. It did not accept that there had been a breach of legislation.
Mike Shepherd, the authority’s interim head, said demand for healthcare was high across the region and hospitals were dealing with more acutely unwell people with complex conditions, which could lead to bottlenecks in EDs at peak times.
“We do our best to admit patients quickly,” Shepherd said. “However, we acknowledge that some service users, like our three whaiora in this case, wait longer in the emergency department than they, or we, would like and we apologise for this.”
Health Minister Ayesha Verrall said: “The experience of these patients is not acceptable, particularly as the majority of people are admitted in a timely way.”
Matt Doocey, National’s mental health spokesperson, said the current health system “just completely fails people in a mental health crisis” and that National would overhaul crisis-response services to provide more intensive support so that fewer mental health patients go to ED.
Frontline staff said the incident illustrated the growing pressures on EDs across the country. Staffing shortages have become so critical in some places that wards are struggling to deliver an adequate level of care, avoid harmful mistakes and protect staff and patients from abuse and violence.
The extraordinary delays for these patients happened soon after Auckland Hospital’s ED became so overcrowded in March that some people were moved into a public space designated as an overflow area for mass-casualty events and several ambulances were diverted to another hospital.
Mental health patients are not the cause of the strain on EDs but have added to it. Community mental health services are overstretched and there are not enough psychiatric beds in hospitals for people with the most severe and urgent conditions.
In many cases, ED is the first port of call for people who are suicidal, psychotic or severely distressed. Often, people experiencing a mental health crisis wait hours to be seen and are then sent home, to be followed up by services in the community. But some patients are placed under the Mental Health Act, which compels them to undergo assessment or treatment and must wait in ED to be admitted to a psychiatric ward.
According to the doctor’s email, the previous longest wait in Auckland’s ED was 70 hours.
Addressing the March incident, Shepherd told the Weekend Herald: “We acknowledge waiting in ED was not ideal. However, it was important the three whaiora remained under the care of hospital services to ensure that they received appropriate specialist care and treatment.”
While the patients waited in ED, hospital authorities across the region tried to find places for them, according to people familiar with those conversations, but none of the patients in Te Whetu Tawera was well enough to be discharged and psychiatric units at other hospitals were full. It took several days before beds could be found in Te Whetu Tawera.
Staff said they did their best to provide treatment and support for the patients while they waited, but that the crowded, chaotic ED was totally unsuitable for someone in a confused and agitated state.
Patients detained under the Mental Health Act may be under a one-to-one watch by a security guard or healthcare assistant and they may not be allowed to go outside in case they run away. Holding them for long periods in the ED, staff say, is unsafe for the patients, staff and other patients in the hospital.
Staff say long stays for mental health patients raise important equity issues because those affected are disproportionately Māori. They often have complicated social and personal circumstances that make them highly vulnerable, have limited family support and nobody to advocate for their rights.
In the email, the emergency doctor said the problem had been raised repeatedly with hospital executives in recent years but “an effective organisational response to improve things has seemingly never been generated”.
“A dedicated sustained project supported at the highest levels of the organisation is required,” the doctor said.
Shepherd said Te Whatu Ora had several working groups in Auckland looking at inpatient capacity and alternatives to admission to ensure all patients receive timely and effective care. Auckland’s ED had made several changes to manage mental health patients, including providing de-escalation training to staff, employing a “mental health nurse educator” in the department, and adopting a new security staffing model.
“We acknowledge there is more to be done in this space and would like to reassure our kaimahi in our emergency departments and mental health services, as well as the public, that we continue to look for ways to improve our system and processes, with a focus on helping to ease the pressure on our services.”
Verrall said the Government was trying to relieve pressure on psychiatric units by providing more options in the community, both for people experiencing a crisis and those who were ready to be discharged after treatment. It was also developing initiatives to recruit and retain more mental health workers.
This week, Verrall announced 24 initiatives intended to relieve demand on hospitals this winter, when demand is expected to surge again. They included “mental health support to EDs”, although there was little detail provided.
Frontline staff at Auckland Hospital say they need more psychiatric beds, more psychiatrists and mental health nurses and better physical facilities for mental health patients in ED, including a dedicated “behavioural health assessment unit” that provides a more suitable space for distressed people to wait in.
“Everything else is just lip service,” one employee said.
The Weekend Herald will continue reporting on the crisis in New Zealand’s health workforce and we need your help. Do you have information on this topic? Have you or someone you know missed out on treatment because of capacity problems? Are you a hospital employee working under difficult conditions? Do you have documents that can help us shed light on these issues?
We want to speak to as many people as possible who have experience in the system, to ensure our reporting is thorough and accurate. You can reach Investigations Editor Alex Spence by email (alex.spence@nzme.co.nz), secure Signal messaging (0272358834), or post (The New Zealand Herald, Private Bag 92198, Victoria St West, Auckland CBD 1142). We can’t reply to all submissions because of the volume we receive. We will not publish your name or identify you as a source unless you want us to.
They allege the Crown ignored Treaty obligations by not engaging with them.