The Health & Disability Commissioner’s office has found that the Canterbury District Health Board breached Right 4(5) of the Code of Health & Disability Services Consumers Rights because it did not ensure cooperation between providers to ensure quality and continuity of services to the patient.

The patient had been admitted to the Emergency Department following an episode of self-harm and a background of anxiety, depression and alcohol use.  It was noted that she had suicidal intent.

The H&DC found that the hospital staff focussed primarily on assessing the patient’s alcohol addiction issues without giving her mental health issues enough attention.  The patient did not receive a coordinated and appropriate standard of care in relation to her mental health issues.  Her transfer to Alcohol & Drug Services did not ensure that her mental health issues were dealt with along with her alcohol addiction issues.

In addition despite the patient wishing to see a doctor without her family’s involvement, this impacted negatively on the service that she was provided.  The family were wanting to give close assistance to her during her recovery but her own choice excluded them from that.  More effort should have been put into persuading the patient to involve her family.  The patient was discovered to be unresponsive and died the same day.  Her parents complained to the Health & Disability Commissioner about the services provided by the District Health Board.

The Health & Disability Commissioner recommended that the District Health Board review and update its service provision framework explicitly in relation to transfer between services and its telephone screening process.  Details of changes made and improvements and the interaction between the various services are to be provided to the Health & Disability Commissioner’s office.  The District Health Board is also to provide an apology for the breach of the code.

Alan Knowsley

Medical Lawyer