Slipshod record-keeping by Southern District Health Board mental health staff has once more been criticised, this time by mental health commissioner Kevin Allan, in a report into the apparent suicide of a patient on hospital grounds.
The man, who had a history of self-harm and suicide attempts, died in 2017.
He had twice tried to kill himself the day before being transferred from an emergency department to an open ward at a different hospital.
The man had harmed himself due to fear of being moved from a secure unit to an open ward, Mr Allan said.
The day before his death, the man had been on an "unsuccessful" day leave and it was planned that he be sent on overnight leave.
However, the man was reported missing at 10.30am that morning.
A patient found his body in the hospital grounds the following day but the man’s family was not notified by the SDHB, which believed police would tell them.
The family instead found out at 3pm, when they contacted police to volunteer their help to find the man.
Mr Allan said there was no easily accessible electronic copy of the man’s medical records, an omission that contributed to the SDHB’s failure to assess him and his level of risk adequately, record key information about him, and formulate a diagnosis.
"The widespread failure of the DHB’s medical and nursing staff to document discussions, decision-making, history, and treatment plans accurately during the period considered points to a culture of non-compliance with professional standards at the DHB at that time."
In 2017 the auditor-general called for all DHBs to upgrade their information systems from paper to electronic form; last year, in response to questions from Parliament’s health select committee on that point, the SDHB said that shift was taking "longer to achieve than anticipated".
Corinda Taylor, of suicide prevention charity Life Matters, has long criticised the SDHB for its continued use of paper records.
"It is disturbing that two years ago we escalated our complaint to the SDHB about its lack of electronic record-keeping and they promised us that they would fix it but they haven’t, and they have had plenty of opportunity."
Mrs Taylor’s son Ross was an SDHB mental health patient when he died.
"We were aware of our son’s substandard, archaic, sometimes illegible handwritten records, which would almost be impossible to review and not necessarily available in an emergency setting," she said.
"It [the man’s death] is all the more concerning because we raised this matter at the HDC investigation into our son’s death in 2013 ... the importance of keeping contemporaneous notes needs to be emphasised."
The SDHB told Mr Allan that its internal review of the man’s death had led to a range of reforms, and that it was developing an electronic health record system.
Board chief medical officer Nigel Millar said: "We have sincerely apologised to his family and acknowledged the failure of medical and nursing staff to fully document discussions, decision-making, history and treatment plans in their care of him.
"The staff involved are sincerely committed to the best outcomes for everyone in our care and to ensuring lessons are learned where the worst eventualities are realised."
The commissioner found the SHDB had twice breached the code of health and disability consumers’ rights, and also referred the case to the Medical Council to consider the care provided by the man’s psychiatrist.
The doctor, who the commissioner criticised for poor documentation of his decision-making, also apologised to the family.
"I know [he] achieved a lot in his life and believe that he had more to give and I am so sorry that did not happen."
Mr Allan’s report was also referred to the coroner.
