The Southern District Health Board failed to recognise that a mental health patient who later died was increasingly unwell, a health watchdog says.
In a report today, Mental Health Commissioner Kevin Allan also faulted an unnamed psychiatrist at the DHB over the case in 2012 and 2013.
The DHB and the psychiatrist have been told to apologise to the young man's family.
The case arose when the man, Mr A, attended and was later admitted to a mental health inpatient service. He had asked that his ears be checked to ensure there were no transmitters in them, and said he could hear voices. Shortly before this he had also gone to a hospital emergency department concerned he was having delusional thoughts due to the use of the drugs LSD and ecstasy.
Mr Allan said Mr A was a well child but sustained concussion in his teens and had been in contact with the DHB's Community Alcohol and Drug Services over concerns about cannabis use.
He was discharged from the mental health inpatient service after a month, on the anti-psychotic medication Olanzopine. The situation was all right for a while but began to deteriorate after about nine months, Mr Allan said. While on holiday with his father, Mr A went to a hospital complaining about anxiety, hearing voices, poor sleep and his belief that he had a microchip in his ear that had been planted by his parents.
He was assessed, given extra Olanzopine and told to attend his usual mental health service as soon as possible. Over the next three months there were significant signs that the man's mental condition might have been deteriorating, Mr Allan said.
He had lost weight, was not attending scheduled appointments and his parents had made a number of phone calls to the mental health service expressing concern for his wellbeing.
The psychiatrist, Dr C, said Mr A was oppositional and irritated by his mother but not psychotic and had no suicidal ideation. Not long after, however, Mr A arrived at his parents' house at 6am one day with injuries. He could not remember what had happened to him, but reported that he had consumed vodka and drugs and been beaten up.
His mother later said these injuries were self-inflicted. She sought a compulsory treatment under the Mental Health Act, saying her son had suicidal tendencies, had cigarette burns and had set a bed and clothes on fire. She said he had also poured paint on the road.
Dr C wrote: "Hard to judge if their escalating concern is a sign of worsening M.S. (mental state) or not."
Soon after this, Mr A was found to have to have died. Mr Allan said his job was not to decide the cause of death but to study the quality of the care provided for him. He said it was a complex case, involving mixed messages at times from Mr A about his parents' involvement in his treatment, and differences of opinions at times between his parents.
However, he said a relapse plan that was developed lacked input from Mr A or his parents. He said the lack of such a plan that had been discussed with Mr A and his family (with his consent) amounted to suboptimal care. As well, Dr C had not made Mr A sufficiently aware of alternative treatment options.
Mr Allan has told the DHB and Dr C to apologise to the family. The DHB must also review the process for developing recovery plans and provide refresher courses for the mental health service staff on the treatment of psychosis and substance abuse as co-existing disorders.
The psychiatrist is to undertake further education and training on recognising deteriorating patients.
Where to get help relating to suicide and mental health:
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7)
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email firstname.lastname@example.org
What's Up: online chat (7pm-10pm) or 0800 WHATSUP / 0800 9428 787 children's helpline (1pm-10pm weekdays, 3pm-10pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.