Press Release – Capital and Coast District Health Board
Work is underway on the eight recommendations made in an independent review of the care of five mental health clients involved in homicides.
The review team investigated the clinical care and treatment of five Wellington and Hutt Valley clients charged with homicide between February 2015 and March 2016.
“We commissioned the review to determine if there were any improvements we could make,” said Nigel Fairley, general manager for Mental Health and Addictions, Intellectual Disability Services for Capital & Coast, Hutt Valley and Wairarapa District Health Boards (DHBs).
“We would like to pass on our condolences again to the victims’ families.”
The service invited families to take part in the review, which two families did.
The reviewers found risk management and service contact to be adequate, but identified improvements that could be made to documentation, staff education, and communication.
The review team made two major, and six supplementary, recommendations. The major recommendations were developing a single medical record for mental health clients, and having greater clarity around the purpose and use of client recovery plans.
Fairley said the health and safety of clients, their families and the public is paramount.
“This review has identified areas we could improve that could help to prevent events like this happening again. Work is well underway on addressing the recommendations.”
“Work is happening at a national level to develop a single electronic health record. In the interim, we are looking at options to improve our current health record system so different sources of clinical information are linked up.
“We have already developed a new document called the Client Pathway, which will replace the existing client recovery plan, and are currently working with staff to set standards around how it is used.
Fairley said the supplementary recommendations, which focused largely on training and process issues, were also being addressed.
An advisory group was established to lead the work on implementing the recommendations from the report. In addition, the three DHB Boards are setting up a joint working group to oversee the improvements.
The reviewers acknowledged the challenges mental health clinicians face, and that they were able to use hindsight when carrying out the review.
“For mental health clinicians, balancing the autonomy and dignity of the person’s decision-making regarding treatment with the need to maintain the person’s and the public safety is a constant tension,” the reviewers said.
“[Mental health clinicians] work with dozens, or even hundreds, of service users who share many of the identified risks, but who do not go on to seriously harm themselves or others.”
The review was led by Professor Graham Mellsop, Professor of Psychiatry at Waikato Clinical School, University of Auckland.
An advisory group was established to lead the work on implementing the recommendations from the report. In addition, the three DHBs are setting up a joint working group to oversee the improvements.
A copy of the report, service consideration of the recommendations, and review terms of reference is available at www.ccdhb.org.nz/news-publications/news-and-media-releases/.
As there has been extensive media coverage of the homicides, all identifying details in the report have therefore been removed to protect the privacy of the clients and their families.