Weekend Herald exclusive: Inquiry asks to see damning report on mental health care

Professor Ron Paterson, chairman of the Government Inquiry into Mental Health and Addiction, during a school visit in June. Photo / Duncan Brown

WARNING: This article is about mental health and may be distressing for some readers.

A damning report into multiple failings in the care of a mental health patient with complex needs, has been requested by a national inquiry.

The Weekend Herald revealed the report's existence in June after the Ministry of Health tried to prevent publication of it.

The case is so sensitive the newspaper cannot publish any details that could identify the patient.

Now the Government Inquiry into Mental Health and Addiction panel has asked for the report to consider its findings.

The highly critical report stemmed from a six-month inquiry into the patient's care, ordered by the Ministry of Health's director of Mental Health and Addiction Services, Dr John Crawshaw.

It was known about by high-ranking officials including former Minister of Health Dr Jonathan Coleman. The current Health Minister, Dr David Clark, has been advised.

The report made more than 100 findings expected to shape mental health services across the country, but at least some of the desperately-needed changes have yet to be implemented.

It highlighted a catalogue of failings.

"There was no long-term care or responsibility taken by any of the specialist child and adolescent psychiatrists, clinical teams or caregivers, beyond their specific facilities," the report said.

Though some specialists and institutions were praised for their efforts, none treated the patient properly for what was thought to be the root cause of the problems, which cannot be identified for legal reasons.

The inquiry found "serious shortcomings" in the services provided to the patient and made findings relating to continuity and consistency of care; clinical decision-making; clinical assessment, diagnosis and formulation; discharge and transfer planning; care and relapse prevention; communication between clinical teams; and Child, Youth and Family (now Oranga Tamariki) placement decisions.

Ministry of Health Director of Mental Health and Addiction Dr John Crawshaw will not say if a patient at the centre of a critical inquiry is still receiving treatment. Photo / File

In a letter attached to the report released more than a year ago, Crawshaw expressed his concern over the patient's treatment, which was brought to his attention by district inspectors of mental health - lawyers who advocate for the rights of patients.

"After careful consideration I have formally accepted the inquiry's findings and recommendations, some of which have significant implications for mental health services nationally," he wrote.

Earlier this month Crawshaw said agencies had responded well to the report and were working toward implementing the recommendations.

"I am satisfied with the progress in implementing recommendations and confident agencies are treating them with the seriousness they deserve.

"I correspond regularly with agencies on their progress implementing the recommendations."

It's understood the report has been released to the district health boards involved in the case.

When asked whether the report would be shared with the national mental health inquiry panel, Crawshaw only said the Ministry would comply with its obligations under the Inquiries Act.

Lawyer Moira Macnab wants openness and full and frank discussion around mental health. Photo / Doug Sherring

The mental health and addiction inquiry panel chairman, Professor Ron Paterson, confirmed the panel had now asked for the report and would consider it as part of its inquiry.

"Yes we are aware of that inquiry and that, because it relates to one current patient, it's excluded from our terms of reference," Paterson said.

"But we have asked the ministry for information about the key findings and recommendations and that information has been shared with us."

Lawyer Moira MacNab, who works for mental health patients and their families, criticised the Ministry of Health for trying to keep the report secret.

"Fundamentally saying nothing hasn't improved mental health services and we've come to a point where there's been years and years of failings. My view is it's only when the community starts responding and asking questions, and more importantly when the media gets involved, that any change occurs," she said.

"I support openness and full and frank discussion because we've got a major issue where most families have somebody in the family or know friends with mental health issues. We've got a problem and we need to sort it."

The purpose of the national mental health inquiry is to hear from people with "lived experience" of poor mental health and addictions, those affected by suicide, and workers in the sector on New Zealand's approach to the issues, and what needs to change.

Submissions can be made online or people can attend public meetings across the country.

The panel will make recommendations for changes to improve services with a particular focus on equity of access, community confidence and better outcomes, particularly for Māori and other groups with disproportionately poorer outcomes.

WHERE TO GET HELP:

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