Ellis inquiry finds mental health inadequacies

By MICHAEL DALY

An inquiry into the care of Paul Ellis, who bashed his father to death two years ago, has found the mental health services in South Auckland inadequate but no individual responsible for the tragedy.

Paul Ellis, a paranoid schizophrenic, broke into his father Tony Ellis' house just before midnight on October 25, 2001, and bashed him to death with a baseball bat as Mr Ellis made a desperate 111 call for help.

Fourteen days before his death, Mr Ellis had had his son committed into care. The Community Assessment and Treatment Team took Paul Ellis to the Tiaho Mai mental health unit, in South Auckland. But a visiting Family Court judge released him later the same day.

In September last year a jury in the High Court at Auckland found Paul Ellis not guilty of murder by reason of insanity.

Findings of an inquiry by Helen Cull QC into the adequacy and timeliness of services provided to Paul Ellis were released today.

The inquiry found the services provided to him were inadequate.

"There was no one factor, incident or person within the (South Auckland Mental Health) service responsible for the tragedy that occurred," the inquiry concluded.

"However, it is a combination of errors, omissions, timing and circumstances which led to the overall inadequacy. It is one of the classical systemic failures, which failed Paul Ellis."

Resource constraints on South Auckland Health had been a contributing factor to the delivery of services to Paul Ellis.

The inquiry pointed to demands caused by excess client numbers, and large caseloads. It said the level of deprivation within the community and the severity of patient illness reduced the service's capacity to provide adequate care to Paul Ellis.

At the time of the killing Paul Ellis had been under the care of the mental health services of South Auckland Health, now the Counties-Manukau District Health Board.

The inquiry found the initial assessment, conducted between 1am and 3am on October 12, 2001, of Paul Ellis when he was compulsorily admitted to hospital by his father, had been timely.

But it found a clinical report form, which was referred to a Family Court judge who carried out a review of the compulsory admission, did not have enough space to show reasons why Paul Ellis posed a serious danger to the health and safety of himself and others.

Paul Ellis discharged himself after the review found he could not be detained compulsorily.

The ICU had been four patients more than it should and the severity of illness in the ward had been unusually high, with staff having to intervene in altercations between patients, the inquiry said.

There had not been an opportunity to assess Paul Ellis in an ongoing manner in the critical period before the review, due to overcrowding on the ward and associated pressures on staff.

The time of the review had also been moved forward an hour from noon to 11am.

"The abridgement of time also compromised adequate communication by the service with Mr Ellis senior about the review hearing and his ability to be present," the inquiry said.

The review decision to treat Paul Ellis in the community and the medication prescribed had been influenced by a psychiatrist's belief that he did not have grounds to re-initiate compulsory processes, and Paul Ellis had appeared more settled and been willing to accept treatment in the community.

Communication between inpatient and outpatient services had been poor and inadequate, the inquiry said.

The discharge referral form had lacked critical information regarding Paul Ellis' diagnosis, medication and priority for follow up.

The community treatment team had been insufficiently assertive in its follow-up of Paul Ellis as, among other things, it lacked relevant documentation and information from the inpatient service.

Following the release of the inquiry findings today, Director of Mental Health Dr David Chaplow said Counties-Manukau DHB had already implemented many of the recommendations in the inquiry report.

Funding increases for mental health services in the northern region, specifically in Counties-Manukau, had been significant since Mr Ellis' death.

"The inquiry revealed overall failings in the system of mental health provision, such as poor communication, misunderstandings, and workforce inadequacies," Dr Chaplow said.

"However, improvements have already been made and will continue. I recognise nothing will reverse the tragic loss experienced by the Ellis family to whom, again, we extend our condolences."

- NZPA

Summary of the Ellis Inquiry findings