Warning: This article deals with suicide and may be upsetting.
Beset by intense headaches a psychiatrist told him was likely irreversible brain damage, Rhys Thomassen lost hope, writing a "death letter" days before he died.
Now a review into his care at a mental health facility has found a series of errors in the weeks leading up to the 24-year-old's death by suspected suicide.
He ran away from an escorted leave walking group on November 11 and was found dead by police at 3.45am, near the Hamilton Central Police Station.
His father Ray Thomassen wants answers about why his son was allowed out of the centre when he had already run away while on leave two weeks earlier.
The review of his care at the centre found:
• Inadequate nursing assessment process resulting in failure to recognise declining
mental health and increased suicide risk;
• Nursing staff copied and pasted clinical note entries;
• Nurses failed to communicate and hand over new concerns or risks to
other nursing and medical staff;
• A cognitive bias negatively impacted nursing decisions and critical thinking;
• Uncertainty of diagnosis and treatment;
• The patient was granted leave after running away from leave;
• Frequent change of residence between the wards.
The Herald asked the DHB on June 12 about the review and why leave was granted to Thomassen when he had told staff about his plans to take his own life, including having written a death note.
The DHB has not yet replied to the questions.
Thomassen, who had a history of behavioural issues, was admitted to the centre on October 7 after making an attempt to take his own life at a non-government mental health unit in Thames.
He told doctors he had ongoing headaches he believed was caused by solvent abuse and begged medical staff to give him electric shock treatment.
A CT scan of his brain was normal and a psychiatrist referred to a childhood diagnosis of Attention Deficit Hyperactivity Disorder and prescribed Ritalin, despite the medication causing problems in the past and the initial diagnosis being rescinded in 2006.
After eight days with worsening head pain the medication was discontinued.
The review found doctors were considering post concussion syndrome and organic brain syndrome as possible reasons for the pain and told Thomassen if he did have brain damage it was likely irreversible, which made the young man more depressed and desperate.
However the review said the clinical notes never gave the impression that there was an assertive active process to ascertain facts and move to an agreed management plan.
"This was illustrated by giving Ritalin and then ceasing it. The history recorded that Ritalin exacerbated his condition," the review stated.
The review identified a cognitive bias, a systematic error of thinking that affects the decisions and judgments, in Thomassen's care.
Clinical notes showed repeated expressions from Thomassen of suicidal thoughts, intent and hopelessness regarding the inability to find a solution for his headaches and depression.
Despite him telling nurses he felt this way, the fact Thomassen was often seen to be interacting socially with other patients was "possibly perceived by staff as a confirmation that he was not as depressed or as desperate as he reported".
"The repeated talk of suicide was overlooked as it was potentially seen as attention seeking," the review said.
The frequent transferring between wards would not have facilitated improved mental health and would have affected his security and stability, Ray Thomassen told the review.
During the 36 days Thomassen was an in-patient he was moved seven times between wards, including one occasion when he didn't want to go back to ward 34 because he said another patient there had touched him inappropriately.
The family also felt this created a loss of continuity of carers and the likelihood of missing subtle changes in behaviour.
Granting leave following an earlier Absent Without Official Leave event was queried by his father.
"The record shows that he went Awol on October 27 and was returned safely. However he did warn that he would [go] Awol again in order to suicide," the review stated.
"Rhys assured the staff he had no intention of running away. He ran off almost immediately the escorted walking group left the Henry Bennett Centre."
Thomassen talked of a "death letter" but when he denied wanting to self-harm an enrolled nurse did not explore it further or request to see a copy of the letter, and the information was not passed on to a registered nurse or doctor.
A suicide letter was found in Thomassen's room following his death.
The review said nursing assessment failed to recognise the change in Thomassen's appearance as a red flag for his declining mental health.
It said poor personal hygiene was a red flag for major depressive disorder and a change in daily functioning should be seen as a warning sign.
In the days before his death Thomassen was noted as being unkempt and not interested in showering.
The review made a number of recommendations including:
• Review the current risk learning package and identify gaps in delivery;
• All admissions to HRBC must have diagnostic and risk formulation completed;
• Review current processes for nursing assessment and clinical documentation;
• Update communication and clinical handover processes;
• Ensure whānau are included in the care process;
• Review nursing rosters to ensure enrolled nurses are always working under the direction and delegation of a registered nurse.
Ray Thomassen said he was unhappy with the review and wanted it revised.
He criticised risk assessments of his son as inadequate and said risk factors were not taken seriously or elevated, and that Thomassen should never have been prescribed Ritalin which he believed made his mental state worse.
He said there was too much emphasis placed on the solvent abuse and accused Waikato District Health Board of excluding him from a court hearing to section Thomassen under the Mental Health Act.
He also sought clarification over the ratio of carers to patients on the day Thomassen absconded from the escorted walking group.
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