Board found wanting in patient's care

Shane Fisher killed himself in 2006 while on home leave from the district health board's mental health unit. Photo / Supplied

Sally Fisher The mother of a patient who took his own life in May 2006 is pleased with a coroner's finding which directs the Auckland District Health Board to improve its standard of care.

But she disagrees with Auckland coroner Dr Murray Jamieson's view that modern psychiatry does not have "the ability to prevent suicide".

Sally Fisher, whose son Shane Fisher died aged 26 under the care of the board's mental health unit, Te Whetu Tawera, said the view was a prime example of the prevailing ideology that suicide is unpredictable.

"Suicide is as predictable and preventable as a stroke or heart attack, if the warning signs are acknowledged and acted on."

She said in her son's case the warning signs were there, but not properly acted on. In part, the coroner agreed with her - especially in regard to the arrangements made for Shane to leave the unit for home visits.

"The mechanism used to provide leave from Te Whetu Tawera for Shane was unsatisfactory and unsafe," said Dr Jamieson in his finding of the inquest into Shane's death.

He said the leave provision form in Shane's clinical notes was confusing, in part illegible and apparently redundant provisions had not been crossed out.

"Even the crossings-out are not clear," he said. "The signature instruction is largely ignored. The chronology is odd. Important sections such as 'Risk and Safety Plan' and 'Early Warning Signs' are blank. Some of the entries mention family agreement [to leave], implying that contact with the family is required."

The latter point was one of Mrs Fisher's key arguments during the inquest, in which she represented herself against a bevy of lawyers, including a QC, representing the DHB and its staff.

She maintained that had she been advised by phone that Shane was coming home for the day, the outcome might have been different, as might have been the case if the unit had followed proper procedure and carried out a safety check and suicide risk assessment.

"It was the one day I never received a phone call. We had no idea that Shane was coming home at that time," said Mrs Fisher.

The board's director of Mental Health Services, Dr Clive Bensemann, said although the coroner noted areas for improvement, he did not find that anything the board did led to Shane's death.

"We acknowledge the coroner's criticism of the leave form in place at that time," said Dr Bensemann. He said leave arrangements were now entered and updated in the multi-disciplinary plan for service users who were required to sign out and sign back in on their return.

"Leave status is reviewed on a daily basis and staff monitor the mental wellbeing of service users to ensure that they are well enough to be granted leave."

He said the board had also addressed the other recommendations made by the coroner. "It is unfortunate but important to recognise that this would not have changed the outcome in Shane's case."

As well as criticising the scant nature of "the final and presumably operative entry" in Shane's clinical notes, Dr Jamieson said the requirement to contact family needed to be specific in each entry in the notes, as did any arrangements made by the family to provide company for the person on leave.

The coroner also recommended that safety assessments and leave times must be recorded immediately in "date/time form" in the clinical notes.

He was critical, too, of the way in which additions to clinical notes were made after the event.

During the inquest last year, the court heard how Shane's notes were added to following a "defusing" meeting after his death, the additions showing up as several different "versions" on his computer record.

Dr Jamieson recommended "version" be replaced by "a term less susceptible to misinterpretation". The board was unable to advise whether the computer system had been updated.

Mrs Fisher said that after the defusing meeting Shane's notes were rewritten and added to - to show that someone did see him before he left the unit.

"I firmly believe that was a made-up story to satisfy everyone and you and I will never know the true answer," she said.

She accepted that many of the concerns she raised during the inquest - such as the standard of Shane's care over a four-year period, the practice of conducting consultations by telephone and the lack of rehabilitation services - were beyond the scope of the coroner.