Canterbury District Health Board failed to provide proper care to a mentally unwell woman in the weeks leading up to her death, a Health and Disabilities Commissioner decision has found.

The DHB have admitted to the wrongdoing and say improvements in the service have been made.

A woman in her 30s was admitted to the Emergency Department at Canterbury DHB following an episode of self-harm.

Doctors noted she had a background of anxiety, depression and daily alcohol use. She was also noted to have had suicidal intent.


The young woman was referred to the Psychiatric Emergency Service (PES) and was reviewed by a mental health nurse the next morning.

The nurse noted "risk of suicide was low but could change depending on her level of intoxication".

She was referred to Alcohol and Drug Service (CADS) who understood that PES would be continuing to work with the woman on her mental health issues.

However, that did not happen. The PES case manager "discharged [her] from mental health services" after not being able to get hold of the woman.

The day after she was discharged, the woman called CAD and initial telephone screening was undertaken but self-harm was not discussed.

Instead, she was referred Alcohol and Other Drugs (AOD) for an assessment in a few weeks time.

Two weeks later, before that appointment, she was found dead.

Mental Health Commissioner Kevin Allan today released a report saying the primary focus was on her alcohol addiction and not enough attention was being given to her mental health issues.


"[The woman] did not receive a co-ordinated and appropriate standard of care for her mental health issues.

"The transfer of her support to alcohol and drug services in the community was insufficient for a consumer dealing with both mental health and alcohol addiction disorders," Allan said.

There was a lack of critical thinking in relation to the co-existing disorders resulting in inadequate co-ordination of care by Canterbury DHB, Allan said.

The Commissioner recommended the DHB reviewed its Service Provision Framework to ensure that it explicitly clarified and documented the transfer processes between services. He requested evidence of these changes.

The DHB were also told by the Commissioner to apologise to the woman's family for its failure to provide proper care.

Chief medical officer at Canterbury DHB, Dr Sue Nightingale, said she had apologised to the family of the woman and expressed her condolences.

"Canterbury DHB accepts the findings of the Health and Disability Commissioner.

"Improvements relating to the Commissioner's recommendations have been made," Nightingale said.