The West Coast District Health Board (WCDHB) has been found to have failed to care for a man at a mental health inpatient unit in 2018, with a suspected suicide attempt leading to his death.
The WCDHB was found to have breached the Code of Health and Disability Services Consumers’ Rights, Mental Health Commissioner Kevin Allan said in a statement today.
The man, who was aged in his 60s and had a history of mental illness, was admitted to the inpatient unit for diagnostic clarification when his condition deteriorated.
He had bipolar personality disorder, a history of low mood and was suffering cannabis withdrawal.
He was considered a moderate to high suicide risk.
Staff at the unit monitored the man over a weekend after he was admitted, with no concerns noted until Sunday evening when he became agitated and refused to take his medication.
He barricaded himself in his room through the course of the night.
Staff undertook observations of the man overnight but for three hours from 6.30am on Monday morning, no visual observations of the man were undertaken.
At 9am, a multidisciplinary meeting took place, during which concerns from man’s sister were conveyed and his presentation was discussed.
Thirty minutes later, the man was found after what was suspected to be an attempted suicide. He died four days later.
The WCDHB was found by the Mental Health Commissioner to have failed to check the man’s room for risk points
They also failed to complete hourly observations of the man after 6.30am, to escalate his care when his condition deteriorated, to fully document a medical plan for care, or to document a nursing plan.
"Given the context, I am concerned that, following admission, a nursing care plan was not developed for [the man], and that the documentation of his medical care plan was incomplete," Allan said.
"In addition, several staff demonstrated a lack of critical thinking about the care that [the man] required overnight, and a lack of initiative in addressing his deteriorating condition."
A number of recommendations were made to WCDHB, including:
· Finalising an escalation policy and provide evidence of training on this
· Audit staff compliance with hourly observation plans
· Assess and provide training on communication and teamwork skills within the team
· Conduct a review of risk assessments
· Audit efficacy of new handover/admission forms to ensure relevant information was captured
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