"Her mood has become lower she no longer enjoys things; weepy and low most of the time. She spends most of the day in bed does not really sleep and sleeps poorly at night. She uses alcohol and gets drunk most nights a week to cope," the GP documented at the time of the phone call, which was included in the HDC report.
The GP requested that the woman be seen by a mental health specialist at the DHB that same day but the assessment was delayed and she died by suicide before it was carried out, the report said.
Mental Health Commissioner Kevin Allan was critical that the DHB had "seriously inadequate" systems and processes in place at the time of the woman's referral.
In particular, there was no formal process for triaging referrals, and e-referrals were managed by administrators without review by a clinician for up to 24 hours, Allan said.
He said clinicians were also unable to access patient medical records easily, and they had to manage crisis calls in addition to their usual caseload.
"The DHB is responsible for the services it provides, and must ensure that appropriate systems are in place to support clinicians to carry out their roles," Allan said.
He considered that the inadequate systems and processes "contributed to the poor standard of care provided in this case, with the result that opportunities to assess [the woman] with the urgency required were missed."
Allan recommended that the DHB update HDC on:
• Its newly developed mental health crisis service manual.
• Conduct an audit of the current process for the management of incoming mental health referrals.
• Provide evidence of caseload reviews carried out for Mental Health Service clinicians and report on the effectiveness of those reviews.
The deputy Health and Disability Commissioner also advised the DHB provide a written apology to the woman's family, which has since been provided.
The patient's family said in the report that they believed their loved one's death resulted from systemic failings and "multiple actions of many people over time", and that in these circumstances she "would not want an individual to be blamed for her death".
They said that they are grateful for the efforts and service improvements implemented in the wake of their loss.
The DHB accepted that there was a need for systemic changes and noted that these have since been implemented.
The nurse said: "This incident has remained with me and has affected me personally and professionally. I have undertaken considerable work since this time to improve my practice and have also continued to take steps to limit situations where I become stressed and overwhelmed."
Where to get help:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• 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)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.
