Counties Manukau failed in handover care of man who died in suspected suicide

The man was discharged from hospital for transfer to a different Te Whatu Ora district but died before that health region made contact with him. Photo / LDR

The poor transfer of a paranoid schizophrenic between hospital regions has been criticised by the Health and Disability Commissioner after the patient later died in a suspected suicide.

The Deputy Health and Disability Commissioner said the then Counties Manukau District Health Board, now Te Whatu Ora Counties Manukau, breached its duties in the discharge, transfer and aftercare plans of the man who died in 2018.

The patient, in his 30s, had a history of paranoid schizophrenia, substance-induced psychotic disorder and polysubstance drug abuse.

He had previous self-harm episodes and was subject to a Community Treatment Order under the Mental Health Act at the time of his death.

The man was meant to be transferred to another Te Whatu Ora district after his discharge from Middlemore Hospital.

However, inadequate transfer of care from Counties Manukau led to a delay by the receiving service in making prompt therapeutic contact with the man.

“This was critical in light of the importance of follow-up after an inpatient admission,” Deputy Commissioner Dr Vanessa Caldwell said in a decision released today.

She found Te Whatu Ora Counties Manukau breached the Code of Health and Disability Services Consumers’ Rights in two ways - not providing services with reasonable care and skill, and lacking cooperation between providers to ensure quality and continuity of services.

“I am critical that, particularly in the context of mental health care, more was not done by Te Whatu Ora Counties Manukau to transfer the man’s care safely. Overall, this led to a poor standard of care at the point of discharge,” Caldwell said.

The man was allowed to travel alone on the day of his discharge without anyone organised to go with him or pick him up, and there was no aftercare plan issued to him or his whānau.

Te Whatu Ora Counties Manukau also did not communicate with the receiving service in a timely way.

Caldwell also had concerns that the second health board did not “establish a timely and critical therapeutic relationship” with the man once it became known he was in its catchment area.

Te Whatu Ora Counties Manukau was asked to apologise to the man’s family and provide the Commissioner with an update on the changes implemented in response to the events.

It was also asked to consider developing a guideline about transport and supervision for transfer of patients, and review work pressures on staff in in-patient units.

Since the death, Te Whatu Ora Counties Manukau said it had increased family involvement in safety planning and its new discharge procedures.