The Southern District Health Board has been told to apologise to the family of a prisoner who died in a suspected suicide, after an investigation found failures in how prisons and health boards communicated.
Deputy health and disability commissioner Dr Vanessa Caldwell this week released details of a case, involving the Department of Corrections, the SDHB, and the Canterbury District Health Board, that raised concerns about the co-ordination of mental health support.
She made a raft of recommendations after finding the the three organisations had breached the Code of Health and Disability Services Consumers' Rights, for an overall poor standard of care for the young man.
The young man, in his late teens, had a known history of mental health issues, the investigation summary said.
Following his release after being in prison for a year, he was remanded in custody at another prison on further charges, and he remained there until he was transferred back to the first prison.
He died from suspected suicide while he was in prison.
Dr Caldwell identified multiple issues in relation to his care and said while individually some of the deficiencies might appear minor, cumulatively they led to a poor overall standard of care.
"The issues illustrate poor co-ordination of care between Corrections and both DHBs, and inadequate transfer of information within or between one service and another.
"Effective co-ordination of care is vital in a forensic mental health setting where a vulnerable person with complex mental health needs is receiving care from multiple providers at the same time, and, often, transitioning between providers."
powered by Rubicon Project
The case highlighted the importance of Corrections and DHBs providing appropriate and co-ordinated care to prisoners with mental health conditions.
"I express my sincere sympathy to the man's family for their loss. Their complaint has given all three services an opportunity to reflect on the care they provided and take actions to improve the care they provide," she said.
She recommended that Corrections and the SDHB provide a written apology to the man's family.
She made a series of other recommendations relating to all three organisations.
They included Corrections conducting a random audit of prisoners receiving care from forensic mental health services, and of staff compliance with policies, and that the SDHB should review its review and discharge process.
Both health boards said they had made changes around communication and co-ordination as a result of the incident.
The SDHB had made changes to the prison liaison assessment to include a comprehensive risk assessment and consent to liaise form. It was reviewing all policies, procedures and guidelines with forensic services.
It had also made a number of other changes, including allowing only one administrative staff member to be on leave at any one time.