The death of a man with a history of mental illness highlights the need for health service providers to work together in unison, the Mental Health Commissioner said.

A report released today by the Health and Disability Commissioner found the Waitemata District Health Board in breach of the Code of Health and Disability Services Consumers' Rights.

Commissioner Kevin Allan said failures related to a man's discharge from the DHB's Community Mental Health Service were to blame.

A short time after being taken home, the man was taken by his sister to see his general practitioner. He had lost a significant amount of weight and was short of breath. The man, aged in his 50s, was treated in hospital but died from pneumonia secondary to malnutrition and depression.


The HDC report said the man had a history of depressive episodes with psychotic symptoms, post-traumatic stress disorder, and chronic obstructive pulmonary disease.

"He was receiving services from two support organisations to assist him to live in the community. These services were funded by the DHB's Needs Assessment and Service Coordination service (NASC)," Allan said in his report.

Mental Health Commissioner Kevin Allan. Photo / File
Mental Health Commissioner Kevin Allan. Photo / File

However, following a visit from the man's key worker and a discussion at a multidisciplinary review meeting, the man was discharged.

The Mental Health Commission was critical of the DHB allowing the man to be discharged while failing to appoint a lead organisation to oversee his ongoing care. He was also critical of support organisations not being invited to the multidisciplinary review, among a number of other incidents:

• That the man was not reviewed by a psychiatrist at the time of the proposed discharge;

• That the discharge summary was not circulated to the support agencies;

• That the discharge was not discussed with the man's family, and that incorrect assumptions were made at the multidisciplinary review meeting about the level of support available to the man from his GP and his family;

• And that the DHB's Needs Assessment and Service Coordination (NASC) service didn't escalate or address concerns about the man's reluctance to receive support services when these were raised by one of the support organisations after he was discharged.


The Mental Health Commissioner said the case surrounding the man highlighted the importance for health service providers to work together.

He recommended the DHB apologise to the man's family and implement processes to improve the discharge process.

It was also recommended the DHB undertake an audit of "compliance with discharge processes and familiarise NASC staff with the Equally Well Consensus Paper to be used in the context of needs assessment and contracting support services."

A DHB spokeswoman said the organisation expressed its sincere condolences to the family.

"The DHB has apologised for shortcomings in communications around post-discharge arrangements in this case. We should have involved the family in the planning of the patient's care in the community.

"We have taken steps to review and improve our discharge processes, with a particular focus on strengthening the communication between external agencies and ensuring these agencies are clear about their role in a patient's care."

Discharge processes now included:

• In complex cases where multiple agencies are involved, a meeting will be organised to determine which agency will assume the lead;
• Confirmation must be provided that transition planning with the GP has occurred;
• Discharge summary to be provided to the patient and other agencies involved in their care
• Our Specialist Mental Health and Addiction Services are designed and resourced to help those in serious or acute distress.

It was not practical for the DHB to provide case management for patients once they were discharged from its direct care, the spokeswoman said.

"This patient had capacity to make his own healthcare decisions and was discharged into the care of home-based community services and their GP. We should have ensured that all agencies involved in the care of this patient met prior to discharge and confirmed which agency would assume the lead."


If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call 111.

Lifeline: 0800 543 354 (available 24/7)

Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)

Youthline: 0800 376 633

Kidsline: 0800 543 754 (available 24/7)

Whatsup: 0800 942 8787 (1pm to 11pm)

Depression helpline: 0800 111 757 (available 24/7)

If it is an emergency and you feel like you or someone else is at risk, call 111.

There are lots of places to get support. For others, click here.​