"My life has been turned upside down. I lost my [child], I lost my house and I could no longer work."
It began in June 2014 when the woman stopped taking her psychiatric medication because of "significant side effects". In July she discharged herself completely from Southern District Health Board's mental health services.
In February 2015, the woman's mother contacted the mental health emergency team to raise concerns about her mental health, saying she had experienced huge weight loss and that she was worried the woman's daughter could be at risk.
A week later the woman's mother again raised concerns and said she had now taken over care of her granddaughter.
A couple of days later the woman was visited by the Māori Mental Health Service for a cultural assessment where they noted a "very strong cultural identity bordering on delusion". They said she remained at risk because of her extreme views regarding diet, exercise and medication.
The registered nurse assessing her said she did not meet the criteria for compulsory admission under the Mental Health Act so a plan was made to continue seeing her under the community mental health programme.
A couple of days later the woman began refusing to see mental health staff and her mother asked that she be admitted for treatment under the Mental Health Act.
The nurse who saw her noted, "It is in my opinion that [she] has an elevated mood and may come to physical harm secondary to extreme diet/exercise views". But, the psychiatrist disagreed saying there were no safety concerns and because of the lack of space in the mental health unit she was best managed in the community.
In the following weeks the woman became difficult to engage with and made plans to move to another town.
In March the woman's mother reported her daughter had been buying large hunting knives but there was no indication she planned to use them to harm herself or anyone else. The mother took the knives off her daughter.
The woman refused to see a psychiatrist and in late March the community mental health team asked for advice as to how to get her to engage but struggled to get a psychiatrist to review her case.
A few days later police took the woman into custody after she "harmed a woman unknown to her".
The woman's mother said she had been up and down over the previous days but had seemed to be doing better.
Allan acknowledged it had been a complex case but said the failings were systems issues for which Southern District Health Board were accountable.
"This decision highlights the importance of having a broader overall care plan for any consumer, which will require timely psychiatric oversight and should always take account of cultural needs," he said.
Allan recommended that the health board assess how its cultural and clinical care could be best co-ordinated and integrated, in collaboration with local Māori communities, and with input from consumer and whanau advisors.
He acknowledged the work the health board had already done in this regard and recommended it provide a further update to the Health and Disability Commissioner in relation to the changes made since this complaint, and in relation to the outstanding recommendations made following its own Serious Adverse Event Review.
The health board also provided letters of apology to the woman and her family.
