Hospital slated for avoidable death

A coroner's inquiry has criticised the care given to a seriously ill Wellington man who walked unnoticed from the city's mental health unit and killed himself, raising worries about patient safety throughout the country.

Coroner Garry Evans said Chad Buckle's death was "preventable" and there were not enough staff on duty at Wellington hospital's psychiatric unit to keep patients safe.

He said nurses were burdened with an "unmanageable" workload the day he died, and evidence at the inquest identified a system of psychiatric care under "serious stress".

"What happened on this occasion should never be permitted to happen again," Mr Evans said.

That has prompted the Nurses Organisation to warn there remain chronic staffing shortages in mental health services throughout the country, putting both nurses and patients at risk.

Capital and Coast District Health Board defended its staffing levels during Mr Buckle's inquest, saying they were comparable with other New Zealand psychiatric wards.

And last night the board, through clinical director of mental health services Dr Murray Patton, said it was not clear what Mr Evans was saying about staffing.

Mr Buckle's family said last night they did not blame nurse shortages alone for Chad's death, and wanted accountability reintroduced to the mental health system, including for staff who did not monitor him properly.

"What lingers is this enormous frustration and sense of waste, and that frustration centres around the fact all these lessons should have been learned before," Mr Buckle's brother, Sam, told the Herald.

"It is all meaningless if nothing changes, and the history of these reports is that nothing does change.

"These same failings, these same symptoms, keep cropping up time after time."

He said staff failed to notice his brother was missing for four hours, and failed to update risk management and case files, despite his being considered a high-risk patient because of threats against family members.

Mr Buckle, 26, died in July last year, the day after walking out of the psychiatric unit and throwing himself off a Wellington College tower block.

The morning he fell, Chad's father telephoned the unit to tell staff he was worried about his son after seeing a serious relapse the night before.

But the nurse assigned to him later left the unit for training, and no one else was asked to monitor her patients.

Mr Evans' report outlined serious systemic failures at Wellington hospital and a psychiatric unit under serious stress.

"It shows the workload of the psychiatric nurses, upon whose shoulders the system largely depends for its proper functioning, to be on that day unmanageable."

He made 11 recommendations to Capital and Coast Health to improve services, and rejected the board lawyer's claim that it was not up to the coroner to decide if Mr Buckle's care was adequate.

He also said while the board said staffing levels were comparable to similar units nationwide "the true question is whether there were adequate staff numbers to manage patients ... safely".

Mr Evans said the court could only reach the conclusion that numbers were "inadequate".

Nurses Organisation chief executive Geoff Annals said if staffing levels are similar at other units, the inference must be that they also will struggle to keep patients and staff safe.

"We keep seeing specific examples of what you could rightly describe as tragedies and scandals, where those problems impact on specific patients."

The hospital has been criticised before for failing to monitor mental health patients, including a man mauled by a tiger at Wellington zoo.