Damning Review into Mental Health Unit

Health & Science

An independent review of an Auckland mental health unit carried out after the suspected suicide of two inpatients is scathing of the facility, finding multiple serious problems including inadequate leadership and model of care, high staff turnover resulting in less experienced staff, an over reliance on medication, and issues with the physical environment of the ward.

The review of He Puna Wairoa, a Waitematā DHB facility, was launched after two deaths within a week of each other in May 2019 at the 35-bed North Shore inpatient unit.

But a family member of a person who died under the DHB’s care who spoke to Newsroom today says more should – and could – have been done earlier to ensure a safer experience for patients if they had been listened to in the first instance.  

“Time and time again we are told to put our hands up for help but this report just shows that when people do ask for acute mental health support it’s not always there. Why did it take four deaths for the DHB to publicly acknowledge what staff knew before the two inpatient deaths? The report today concedes staff knew the building and nursing model weren’t keeping people safe. People at the top were asleep at the wheel. Why weren’t the DHB Chief Executive or DHB Board thundering down the ward to find out what was going on long before their unit became so broken and people lost hope?”

“If you have a loved one who is in need of specialist support, keep pushing for the right help and be prepared to fight for it.”

Mentioned only briefly in the review is the death of two further people who also died by suspected suicide and were still under the care of Waitematā DBH: one who had recently been released from He Puna Waiora and another who was in a respite facility at the time of death.

“Loved ones are placed in an acute mental health unit like He Puna because their life is at risk. We expected them to be treated with respect and dignity and to be offered opportunities to recover and get well. Instead, our experience was that people are given drugs to get stable enough to be pushed out the door without a safety plan and without psychological therapy in the community – the report says there was a six month wait,” says the family member.

“People end up leaving hospital and enter a world where they can’t cope and there’s no specialised support like therapy to get them through. That’s when they lose hope because they can’t find a way through.”

The family member says while the review was scathing it would have been far worse if they’d looked at the bigger picture.

“The review panel was muzzled by a narrow terms of reference – it only hints at issues that contribute to our devastatingly bad system such as a lack of outpatient services, lack of inpatient and outpatient therapies and overworked outpatient psychiatrists, psychologists and CATT teams.”

The external review, which the Waitematā DHB say they commissioned immediately following the inpatient deaths, focused on the physical safety of the ward environment, governance processes, the team culture, communications policies – particularly with family and whānau members – and quality of care for patients.

Director of Mental Health Derek Wright dismisses the idea that the review should have looked at the community deaths as well.

“There was only two deaths in the unit and the review was about He Puna. But I do acknowledge there were two other deaths, one in the community who had been discharged about a month beforehand and another person who was in a facility in west Auckland. They were both still under the Waitematā DHB care.

“But there was also individual adverse event reviews so each of these suicides was reviewed individually and a number of the recommendations in the summary report are rolled up with the individual reviews.”

“Bear in mind just two years ago there was a whole major mental health inquiry, which actually looked at the whole mental health and addiction system and out of that came He Ara Oranga [Ministry of Health-led independent inquiry into mental health and addiction], which has a number of recommendations that all DHBs are working through, so I suppose you could have gone with another completely overarching review of the wider system, but this was because there’d been two individual cases in He Puna – it was about looking at the functioning at He Puna.”

He apologised to the families of those who died and says many of the report’s recommendations have already been implemented at the facility.

“We fully accept the recommendations of the report and we also accept the criticisms. At the end of the day families have lost their loved ones and for that I sincerely apologise on behalf of the DHB and some areas of care were not as they should have been and we can’t walk away from that we have to accept that.”

“There’s been a huge amount of work that’s actually taken place since then (deaths) so lots of what’s in the recommendations have already been implemented.”

He says He Puna Waiora is a “different and safer unit today than it was in May 2019.”

The review describes feedback from staff, patients (labelled ‘consumers’) and whānau and family of the patients, much of which is harsh in its criticism of He Puna Waiora.

“There is a focus on unwellness, which encourages people to take on the identity of being chronically unwell rather than being encouraged towards a more recovery- focused perspective. There was stigmatisation of long-stay people as ‘bed-blockers’.”

Family and whānau spoken to for the review described examples of “unskilful and unsympathetic care by some staff” and that it was “difficult to find staff who were knowledgeable about, or responsible for, the support of their family or whānau member.”

“The families and whānau were critical of all aspects and levels of leadership, particularly in relation to accountability. They felt that improved leadership across the board is required for the transformational change they deem necessary…in order for them and the community generally to regain trust and confidence in HPW and Waitematā DHB services more generally.”

Despite the clear risk of “suicide contagion” the panel found there was “no document or protocol to guide the staff after a death by suicide.”

“Clinical administration processes (e.g., meetings, clinical note system) were often described as inefficient and ineffective. Particular concerns about clinical record keeping, identified by multiple interviewees, included reports that clinical notes were often perfunctory, clearly “cut and pasted” from previous entries, without content specific to the most recent status and situation of the client.”

The report makes eight key recommendations which includes strengthening the leadership and culture of the facility, a larger focus on patients and their families and whānau with more individualised care, and changes to the physical environment to promote patient wellbeing and safety.