The acute inpatient mental health service at the Middlemore Hospital campus has been faulted over the death of a patient.

Mental Health Commissioner Kevin Allan, in a report released yesterday, listed a series of failings with the DHB’s care of the man leading up to his death and concluded the Counties Manukau District Health Board breached the Code of Patients’ Rights.

He also expressed concern that the level of nursing care for the man “was unacceptable” as the nurses had not carried out adequate risk assessments or responded appropriately to changes in the man’s mood and behaviour or his friend’s concerns.

The man was admitted to the DHB’s acute mental health unit on a Friday afternoon in 2014 under a compulsory treatment order (and put under 15-minute observations) after being found wandering outside Auckland airport appearing dazed and confused after an international flight. On the Monday morning he was found unconscious in his room and was unable to be resuscitated.

The commissioner’s expert nurse advisor Dr Tony Farrow said the nursing staff’s risk assessments of the man were inadequate; they did not appropriately respond to the man’s deterioration in mood and they should have requested an urgent risk assessment from a registrar or consultant after the man’s visiting friends shared their concerns that the man was talking about making a will.

Among his recommendations, the Commissioner also suggests the DHB consider having psychiatrists on duty at its acute mental health unit during weekends and public holidays.

The DHB said changes that have been made following the incident in 2014 include having a Medical Officer of Specialist Scale on duty every weekend; an on-call psychiatrist does a clinical review of all new inpatient admissions within 24 hours; a new clinical handover procedure has been adopted; and a serious incident review has led to 10 recommendations looking at after-hours practice and ensuring staff are able to provide appropriate assessment and treatment of clients experiencing drug or alcohol withdrawal issues and can liaise with ED about mental health patients with complex medical co-morbidities.


Police found a man wandering outside an airport following an international flight.

The man appeared dazed and confused. He was taken to a police station, where he was seen by a consultant psychiatrist and a duly authorised officer/social worker.

The psychiatrist recorded her impression as: “Psychosis NOS [not otherwise specified] — possibly associated with mood disorder, possibly drug-induced. History of polysubstance abuse.”

The man was admitted directly to a psychiatric inpatient unit and placed on observations every 15 minutes. A second psychiatrist recorded that he believed that the man was mentally disordered and a temporary compulsory assessment and treatment order notice was issued.

At 2pm that day, a Friday, the man was reviewed by a consultant psychiatrist, who decided on a plan that included further assessment and monitoring for signs of withdrawal. She recorded a request that the man be reviewed by a registrar the following day (Saturday) and on Sunday if necessary. However, the man was not reviewed again by a psychiatrist during his admission.

At 5pm, a house officer conducted the man’s admission physical examination. The house officer recorded a history of substance abuse, chronic pain, and anxiety. There is no record of a risk assessment.

On Saturday the man’s mood appeared low; he was subdued and kept to himself, but approached staff to have his needs met. He is recorded as showing no signs or symptoms of withdrawal. The house officer reviewed him again, but did not request a review by the on-call psychiatrist or undertake a risk assessment.

On Sunday afternoon the man was visited by two friends. After they expressed concerns about the man to the ward clerk, the man’s allocated nurse was called and spoke to them.

The friends told the man’s nurse that they thought the man was “low and distressed as he was expressing thoughts of wanting to make a will as he believed that he would not be able to make [it] out of the hospital”. The nurse said she asked if the friends knew whether the man had any suicidal intention or plans. They were unable to identify any, but said that he was dissatisfied with his recent trip.

The friends also told the nurse that the man had had a psychiatric admission two years ago, had been using LSD for the previous two weeks, and had begun to identify himself as the “Messiah”. The nurse mentioned the conversation to another nurse and recorded it in the progress notes, but did not seek a medical review.

At around 5.30am the next day, a psychiatric assistant saw the man standing by his open door acting unusually. He was told to stay in his room until 6am when breakfast was due and the man responded by slamming the door and sitting on his bed – and then started to pace back and forth. Just before 6am he asked for extra blankets and at around 7.15am was seen lying on his bed by the night nurse during handover, apparently sleeping

Handover finished around 7.40 am and the morning shift nurse asked whether the man had been seen eating breakfast and was told he hadn’t. At around 8am two nursing students offered to check the man’s blood sugar levels as he had type 2 diabetes, and found the man unconscious in his room. Sadly, the man could not be resuscitated.


The DHB did not provide services to the man with reasonable care and skill, and breached Right 4(1) because staff failed to:

  • arrange a psychiatric review of the man on the Saturday and Sunday
  • assess the man’s risk  sufficiently following his admission
  • respond adequately to his changing presentation
  • monitor him for signs of withdrawal after Saturday, as required by the plan made by the psychiatrist
  • respond adequately to the concerns expressed by the man’s friends and the information that he was talking about making a will.


It was recommended that the District Health Board:

  • reported back to HDC on the implementation of the recommendations of the Serious Incident Review Triage Team
  • conducted audits of the new standard operating processes and policies and procedures
  • provided further training to staff on patient risk assessment, and the clinical documentation of patient presentation
  • audited the use of risk assessment documentation for patients presenting with possible substance withdrawal, significant risks, or suicidal ideation, or who are receiving compulsory care under the Mental Health (Compulsory Assessment and Treatment) Act 1992, to ensure that the documentation meets professional standards
  • considered whether a registrar or consultant should attend the inpatient unit each day over the weekend and on public holidays
  • included a discussion of psychiatrist input into inpatients at weekends at the next meeting of the Mental Health Clinical Directors of the DHBs.

The full report can be read on the Health & Disability Commissioner’s website.


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