Seriously unwell patients were discharged too quickly from Auckland's acute mental health facility because there weren't enough beds.
The near-constant capacity problems at Te Whetu Tawera created tension between the unit and community mental health organisations who sent people in for help.
Staff at the Auckland DHB facility reported "spending too much time fire fighting", "tension/angst amongst staff" and "no time for triage", documents reveal.
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Some patient transfers were declined because there weren't enough beds, and others were "discharged before they are clinically ready".
Te Whetu Tawera is located on Auckland City Hospital grounds and has 58 beds, including 12 intensive care unit beds, for acutely unwell patients including those with schizophrenia.
The facility has come under recent scrutiny.
In 2018, a judge called for an investigation into Gabriel Yad-Elohim's treatment, after he committed a murder three days after discharge.
The delusional Korean-born man delivered an estimated 90 blows to Michael Mulholland's head and body after pulling him from the front door of the 69-year-old's Western Springs flat on September 26, 2017.
An Auckland DHB review concluded Yad-Elohim's treatment had been appropriate, despite Te Whetu Tawera being under "considerable occupancy pressure" which "contributed greatly to a hasty discharge", "places considerable burden on staff" and means "normal planning processes are abbreviated".
Documents now obtained by the Weekend Herald under the Official Information Act reveal capacity problems have continued and "contributed to an increasing level of tension" between the DHB and the community services that send people for help.
Implementation of an improvement project started in September. A report summarised the reasons for change: poor discharge planning, and "the pressure for in-patient beds can often mean service users are discharged before they are clinically ready".
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"The impact is negative service user experience and outcome, increased pressure on the community mental health service groups, and increased risk to service users due to the inability to access appropriate service in a timely manner."
PowerPoint slides summarising staff feedback included concern over admission delays, a lack of time for triage, and too few beds on the weekend, when only one consultant was on call. Other feedback included resources being geared towards an 8am to 4pm timetable, despite 70 per cent of admissions happening outside those hours.
Parts of emails released to the Weekend Herald include an incident report from September: "Attempts by community team to readmit were unsuccessful, as we were advised that due to bed shortage she would not be prioritised as she was not of imminent risk."
In a letter accompanying the information release, Auckland DHB chief executive Ailsa Claire said the region's population was rapidly growing and ageing, and that had increased demand for all services.
The unhappiness referred to in documents are "natural tensions that have arisen between professionals in the community and the hospital setting, all committed to providing the best possible service to their patients".
"We acknowledged that the system was not working as well as it could be and took action to address this, implementing the patient flow project ... since the implementation of this project, inpatient and community services have taken a joined-up approach to resolving the complex issues underlying the inpatient unit regularly being at capacity."
In further comment, a DHB spokeswoman said the project was due to finish in September next year, and "early signs are positive". Current bedspace would not increase, and the DHB was unable to say by deadline whether patients were potentially harmed because of the capacity problems. The improvement project was not prompted by the Yad-Elohim case.
Pressure has been felt elsewhere.
Capital & Coast DHB, which covers Wellington, upgraded the risk from sustained acute demand for mental health services from "high" to "extreme" in August, after a fire at the Te Whare O Matairangi facility in February reduced the number of beds available.
"Recent delays in bed access have resulted in adverse events occurring," an internal document stated. "Acuity/complexity of clients and staff shortages due to vacancy and sick leave are also impacting on demand pressure."
Dr Nigel Fairley, general manager of mental health, addictions and intellectual disability services, said repairs completed by the end of September had restored capacity. The delays referred to relate to one patient, he said, "and have not resulted in the client suffering serious harm or death".
An ongoing nationwide strike of DHB psychologists has put a spotlight on hospital-level care. An open letter to the Prime Minister and Health Minister was published this month by a group of psychologists at Auckland and Counties Manukau DHBs, and warned: "Vulnerable people have to wait up to a year or even more for access to the treatment they need - and some are dying by suicide while waiting. Others are not even getting in the door."
The 2019 Budget allocated $1.9 billion of new spending over five years to mental health initiatives, including a new service that will place trained mental health workers in doctors' clinics, iwi health providers and other health services. The ministry is working through requests for proposals for $30 million worth of new frontline services.