Care failures in 57 deaths

Shane Fisher killed himself while on day leave from Te Whetu Tawera. Photo / Supplied

Ambulance staff failed to find a hospital unit 150m from its A&E department, district health board reports have revealed.

The case is among dozens involving the deaths of 57 mental health patients that led to reviews ordering improvements in care.

The deaths occurred nationwide in 2007 - the latest year for which figures are available.

It is the first time figures from district health boards have been collated and they reveal the full extent of problems in the over-burdened system.

Among the failures were the separate suicides of two patients at the Te Whetu Tawera unit at Auckland Hospital.

Both involved problems getting ambulances to help - even though the hospital's A&E department was only 150m away.

One came after mental health staff failed to provide "effective information" to emergency services when making a 111 call.

Auckland District Health Board mental health service director Dr Clive Bensemann said information cue cards had since been provided to all acute mental health staff for calls.

In the other case, ambulance staff did not know where Te Whetu Tawera was, causing a delay of 20 minutes.

But faster help would not have saved either patient, said a hospital spokeswoman.

Reviews of other deaths revealed mental health staff did not have medical records needed to make proper judgments, communication bungles caused confusion and patients had gone missing.

They also found staff had high workloads, emergency medical equipment was missing and, in one case, psychiatric treatment could have made a physical condition worse, leading to a patient's death.

Those who lost their lives include Colin Moyle, killed by Auckland mental health patient Matthew Ahlquist. Reviews found multiple failures by the service.

The information was compiled after Official Information Act requests were made to the country's 21 boards. It is scheduled to be released publicly by those boards today.

It lists each "sentinel" (serious) event at each of the boards.

The information contained the number of mental health patients who died in care and the number who died where reviews later found their care could have been improved. It has led to renewed calls for a system-wide review, by families of mental health patients who have lost their lives.

Sally Fisher, whose son Shane took his life in 2006 while on day leave from Te Whetu Tawera, is among those calling for change.

She called for greater effort to care for the mentally ill who left hospitals for treatment in the community and an end to telephone counselling, which saw mental health staff checking in with patients by phone.

The new minister in charge of mental health, Associate Health Minister Dr Jonathan Coleman, said reviews were unnecessary when some of the system's worst problems were obvious and it was up to experts in the field to find solutions.

He was concerned about high occupancy rates at some residential units - Te Whetu Tawera, for example, had operated well above the ideal occupancy rate of 85 per cent for almost a year - and there were questions about whether patients transferred to community care were getting appropriate treatment.

Coleman intended ordering a review of spending on non-governmental contractors who provided community mental health care.

He did not believe boards had "a huge handle on what they were getting for that money".

Staff retention was an issue across the entire health sector but had become "increasingly" difficult with the mental health workforce.

He had also asked for a briefing about why cash paid to boards exclusively for mental health care was not always being fully used.

Coleman has been in the unusual position of being briefed by a professional colleague - a North Shore GP - who lost his son to suicide.

The GP, who spoke on condition of anonymity, said he felt stonewalled in dealings with the board and other health agencies.

Coleman said relatives should be able to get proper assistance.

"Families deserve explanations and I wouldn't want to see bureaucratic barriers put in the way of letting them know what has happened."

Mental health commissioner and independent watchdog Peter McGeorge said the most common failure in the sector was lack of continuity of care.

McGeorge is due to meet the new minister this week.

He said he would also tell the minister that funding had to be increased during the recession, which was likely to increase the workload on mental health staff.

REVIEW GUIDELINES

Improvements to care were ordered after the following cases:

Death of outpatient in fire.
Review found: Follow-up admission to community treatment centre delayed.
Changes: Extra psychiatrist employed.

Suicide of outpatient.
Review found: Community mental health team had high caseloads.
Changes: Caseloads reviewed.

Suicide of inpatient.
Review found: Risk level not accurately assessed, lack of consistency in care.
Changes: New guidelines developed for managing patients with complex needs.

Suicide of inpatient.
Review found: Period between observations too long, no adrenalin for cardiac use on emergency trolley.
Changes: Review of observation policy, adrenalin for emergency use.