A scathing report has found “significant failings” with Canterbury mental health services.
It recommends major changes to prevent a repeat of the “tragic events of 2022 and 2024”, when psychiatric patients murdered innocent people in the community.
An urgent review under Section 99 of the Mental Health Act was ordered in 2022 after Hillmorton Hospital in-patient Zakariye Hussein stabbed Laisa Waka, 53, outside her Christchurch home while he was out on community release.
And in October last year, another of the hospital’s mental health patients, Elliot Cameron murdered 83-year-old Faye Phelps in her garden.
Ministry of Health Director of Mental Health Dr John Crawshaw and Health NZ National Director, Mental Health and Addictions Service Enhancement Phil Grady are holding a press conference at midday as the report is released.
It will be livestreamed from the top of this article.
The Section 99 ‘Inspection into Canterbury – Waitaha Adult Inpatient and Associated Mental Health Services’, released today, was ordered to find out whether there were “systemic issues” with the services.
Nine key findings were made.
The first was that the region’s mental health services were struggling under the weight of “accumulating legacy impacts” from earthquakes, the Christchurch terror attack, Covid-19, and a 35% prison population increase over the past decade.
The events had “heightened demand for services” and caused long stays for patients due to ongoing impacts on housing, blocking community reintegration and delaying admissions.
Critical staffing shortages were the most significant and prevailing issue, the report found, with daily struggles to maintain minimum safe staffing levels across adult inpatient, community, and forensic services.
Forensic mental health services faced particular challenges, with concerns over an imbalance in the junior to senior staff ratio that could lead to safety risks.
Bed closures, early discharges, and reduced interventions have followed, causing re-admissions and pressure across the care continuum.
Staff morale was described as poor, with reports of burnout, “a culture of blame” and “significant disruption to staff learning and development”.
Mandatory training and clinical supervision had been cut back, worsening morale and compromising safety.
A “siloed culture and care model” impeded cohesion between disciplines, while the incorporation of te ao Māori remained inadequate, the report found.
Another key finding was ineffective governance, with clinical governance described as reactive and focused on “immediate issues at the expense of longer-term stewardship”.
Escalation processes were said to be difficult, and quality and safety data were poorly integrated into frontline teams. Regional leadership had delayed decisions on business cases aimed at fixing staffing and seniority gaps.
Recommendations focused on three main areas: governance, care model, and resourcing, with a goal of better co-operation between leadership and service delivery so staff can “do their best” and plan for the future. They included:
It was further recommended that all staff should be involved and valued and make it clear that “bullying in all forms is unacceptable”.
Serious incident reviews also need improvement.
The decisions around patients getting leave into the community have also been “significantly improved”, Grady said, with independent weekly audits of all leave decisions now taking place.
Both Grady and Crawshaw met with Laisa Waka’s family yesterday, a meeting Grady said was one of the hardest he’s ever experienced.
“They have been through significant trauma and are still trying to understand the events and what happened.
“I am deeply sorry these events have occurred,” he said.
Health New Zealand says it is “committed” to implementing the report’s recommendations to try and “prevent the tragic events of 2022 and 2024 from happening again”.
“We recognise the loss and grief these families have and continue to experience and express our sincere condolences to them,” said Grady.
“We are deeply sorry for the failings in our systems.
“We have reached out to these families to apologise and discuss Dr Crawshaw’s report, and will remain in contact, if that is their choice, to update them on progress to implement actions from the report.
“We accept all of Dr Crawshaw’s findings and have an action plan in place to implement the recommendations, which focused on the underlying issues related to governance, the care model, and resourcing.”
Grady said Health NZ is focused on giving senior leadership oversight of planning for the service, building a framework, and “ensuring there is sufficient staff with the right level of training and experience to safely and effectively deliver services”.
As noted in the report, Health NZ said there has been “demonstrable progress” on key recommendations, including establishing a clinical governance framework and increasing clinical staffing by 11% since 2022.
Clinical decision-making on patient leave is now consistent with policies, Grady said, and there are weekly audits of compliance in place.
“There are clear pathways both within the service and nationally within Health NZ to escalate and manage risk,” he said.
“To ensure progress of the recommendations continue, we welcome Dr Crawshaw’s increased oversight of the service over the next 12 months.
“We are committed to improving the service and our actions will be closely measured against this report, and two other event reviews conducted by Health NZ.”