In his report released by the Health and Disability Commissioner's office yesterday, Kevin Allan found the Southern District Health Board and the treating psychiatrist both breached the patients' rights code by failing to provide services with reasonable care and skill.
The report does not disclose the death was suicide, and Mr Allan said his report had not sought to determine the cause of death.
Corinda Taylor, of Dunedin, released a family statement about their ``son and brother'' Ross Taylor, who is not named in the report.
He was 20 when he died.
The family hoped the death would be a catalyst for ``better outcomes for people seeking care in general but in particular young people like their son and brother'', the statement said.
An internal investigation ``failed to deliver anything of real substance'', delaying necessary changes to the service.
``The family ... believes that they could have been better informed about the risks of [the] first episode of psychosis and that Ross was suicidal.
``This was as a result of a highly defensive stance taken by the Southern District Health Board and the psychiatrists concerned throughout the internal investigation processes.
``Shortly before Ross died he asked for help from services which was not followed up properly and unfortunately not highlighted in this report.''
Mrs Taylor said the past five years had been ``heartbreaking'', and she did not want another family to have that experience.
``Today [we] are thinking about how Ross has suffered and the pain that he experienced.''
In his report, Mr Allan said Ross Taylor, referred to as Mr A in the finding, was admitted to hospital after reporting he could hear voices.
He requested his ears be checked to ensure there were no transmitters in them.
Mr Taylor was discharged a month later into the care of a psychiatrist and psychiatric district nurses.
He was taking olanzapine, an antipsychotic medication.
Over a period of 10 months, he was seen regularly by the mental health service, the report says.
During this period, Mr Taylor's antipsychotic medication was decreased progressively.
Mr Allan said there were clear signs Mr Taylor's mental state was deteriorating, and he needed antipsychotic medication.
He said the DHB and the psychiatrist did not make Mr Taylor sufficiently aware of alternatives to olanzapine.
``Mr A had been experiencing problems with taking olanzapine, such as a perceived sedative effect.''
Mr Taylor's parents sought hospital-based treatment for their son, and sometimes disagreed with the mental health team, particularly the psychiatrist, about their son's condition.
The psychiatrist, referred to as Dr C in the report, appeared to be critical of Mr Taylor's parents.
At one point he wrote: ``Overall, [the patient's] account is at odds with his parents' concerns and that he is depressed or drug addicted.
``His account today is very believable and that of his parents has often appeared based on their anxieties rather than observation.''
Mr Allan said Mr Taylor's relapse recovery plan was developed without input from the patient or his parents, which amounted to ``sub-optimal care''.
``The man's mother subsequently telephoned the mental health service a number of times stating that she did not know her son's current whereabouts and asking for him to be hospitalised.
``Sadly, it later transpired that the man had died.''
Mr Allan has asked the Southern District Health Board and the psychiatrist to apologise to Mr Taylor's family, and suggested further training for the psychiatrist.
Recommendations for the health board include an independent audit of mental health documentation and a review of processes for patient recovery plans.
Mr Allan said he could find no evidence the health board tampered with Mr Taylor's patient records after his death, which Mr Taylor's parents had alleged.
However, improvement was needed in the way contact with family members was documented, Mr Allan said.
``[The parents] said that, in the 10 days immediately before Mr A's death, they made numerous telephone calls that are not recorded.''
Responding yesterday, SDHB chief medical officer Dr Nigel Millar expressed ``sincere sympathy'' for the Taylor family.
He said the board had written to the family to apologise for the shortcomings.
``The mental health, addiction, and intellectual disability directorate has commenced implementation of the recommendations ... ''
``These have been incorporated into our continuous quality improvement programme and we are confident these will be implemented within three months,'' Dr Millar said.
The coroner is yet to rule on the cause of Mr Taylor's death.
Where to get help
Lifeline: 0800 543 354 or 09 522 2999
Suicide Prevention Helpline: 0508 828 865 (0508 TAUTOK0)
Youthline: 0800 376 633 or free text 234
Samaritans: 0800 726 666
