Coroner criticises DHB over man's suicide

Auckland Hospital's Mental Health Unit, Te Whetu Tawera. Photo / NZ Listener

A coroner has made a series of recommendations to Auckland District Health Board after ruling that a patient killed himself.

Dr Murray Jamieson said the DHB should review its leave policies at the Auckland mental health unit, Te Whetu Tawera, and ensure that paperwork is completed correctly.

He said the "mechanism" used to provide leave from Te Whetu Tawera for Shane Fisher was "unsatisfactory and unsafe".

Mr Fisher, 26, died at his family home in May 2006 after being diagnosed with schizophrenia. He became mentally ill soon after the death of his brother Glen, who died of blood poisoning caused by meningococcal disease.

On May 20, 2006, Mr Fisher left the mental health unit and walked the short distance to his parents' home. He was later found dead there by a younger brother.

His mother, Sally Fisher, represented herself at the Auckland District Court hearing last year. She said it was a failure of the hospital to allow him to leave the unit without notifying her or her husband.

However, the DHB argued at the hearing that that was not standard procedure.

In his ruling, Dr Jamieson recommended that the health board review the policy regarding leave from the mental health unit, that staff use leave forms consistently and correctly and that family are notified properly.

He also said safety assessments at times of leave should be thorough and recorded properly in patients' notes.

Mrs Fisher told the inquest last year that she had been phoned by the hospital when her son had been coming home on leave in the past but that had not happened on the day he died.

She had been worried about the risk of suicide if he was at home because she knew he would be there alone during the day.

She also demanded answers on what she said was inadequate note-taking - including whether a risk assessment was done before he went home.

In a rare move, the coroner allowed evidence in an inquest involving a self-inflicted death to be reported because the man's family wanted it made public.

Dr Jamieson said last year that it was unusual for a family to want publicity but congratulated them on taking the stance in the hope some "good could come out of the death of a much-loved son".

Giving his ruling, he continued to suppress the names of Auckland DHB staff involved in the case and barred media from saying how Mr Fisher took his own life.

He thanked Mrs Fisher for her assistance in the case and the "poise with which she conducted herself on what must have been a very emotionally demanding occasion".

The DHB's Director of Mental Health Services Dr Clive Bensemann said: "Every death of a patient is tragic and we feel for the Fisher family as this still must be distressing and painful for them."

"We are confident we provided Shane with good care during his last admission and he was making good progress. However, as the Coroner points out, there is always a threat of suicide with patients who have serious mental illness and as much as we work extremely hard to do everything to prevent this, unfortunately deaths do still sometimes occur."

He said the recommendations made by the coroner have already been addressed and added: "It is unfortunate but important to recognise that this would not have changed the outcome in Shane's case."

- NZHERALD STAFF