KEY POINTS:
Health officials are investigating the death of a patient who had attempted to take her own life at central Auckland's acute mental health unit - five months after an external review slammed the unit over a series of deaths.
In the latest case, the patient, understood to be
a woman, died last week at Auckland City Hospital after trying to kill herself at the nearby acute unit, Te Whetu Tawera.
The Auckland District Health Board's general manager of mental health services, Fionnagh Dougan, said yesterday a "root-cause analysis" and serious incident review had begun. The coroner for central Auckland was also investigating.
Ms Dougan said the board's inquiries would take some time, but the initial indications were that there had been no lapses at the unit.
The case turns the spotlight back on the board's adult mental health services after the external review by a three-strong team including Dunedin psychiatrist Dr Stephanie du Fresne.
A similar review is under way in Christchurch after the deaths this year of three psychiatric inpatients in the care of Hillmorton Hospital.
The Health Ministry's director of mental health, Dr David Chaplow, said he was told of the Auckland death last week, ahead of a meeting with the board's chief medical officer, Dr David Sage, on Thursday at which they discussed the new case and progress since the external review.
"We watch out for any pattern," said Dr Chaplow. "If it looks like any systemic issue, we're on to it. In Auckland, with that cluster of deaths we were fairly quick to move and we will be looking at this latest death to see whether that fits a pattern."
The du Fresne review followed four deaths last year: Matthew Ahlquist's alleged murder of Colin Edward Moyle in Sandringham after Ahlquist was discharged from Te Whetu Tawera; the suicide of a man in an open ward at the unit; the apparent suicide of a man at the unit; and the death of a patient at night after admission to its intensive care unit. The review team also considered two other cases.
They concluded that all six showed "unacceptably poor clinical judgment and practice" by some staff.
"We consider that this has occurred because of a lack of appropriate leadership in medicine, nursing and management within Te Whetu Tawera.
"Policy initiatives, which are of inherent value, such as bicultural practice; a patient-centred focus; a recovery focus; minimisation of coercion; and the care co-ordination project have been introduced, but have not been effective in addressing the problems, and have been subject to distortion, and to being thwarted wholly or in part."
Risk assessment processes and documentation were used inconsistently, they said.
In two of the cases, they commented on a lack of observation of the patients.
Ms Dougan said the board had made a number of changes in line with the review's recommendations, including greatly strengthening the patient observation process and appointing a senior nurse to the unit's clinical leadership.