A psychiatrist and the Southern District Health Board have been criticised over the care of a woman who was found dead at home.
The woman, in her 60s, suffered deteriorating mental health following an accident in which she suffered injuries and was left in pain.
Mental Health Commissioner Kevin Allan said she referred herself to mental health services and was diagnosed with major depression.
He said the unnamed psychiatrist, Dr B, was her lead clinician, with backup from a registered nurse as her key case worker, RN C.
The woman, Mrs A, was prescribed antidepressants and sedatives and repeatedly insisted she was not at risk of suicide.
However, she self-harmed twice, one week apart, between 2013 and 14.
Each time she was admitted to hospital inpatient mental health services, being discharged home seven and nine days later respectively, with a plan that she would receive regular follow up by RN C or another nurse, RN D.
However, the woman continued deteriorating mentally and physically. Three days before she died she was visited by Dr B who opted not to invoke provisions of the Mental Health Act and require her to return to hospital for compulsory mental health treatment.
Mr Allan said many aspects of the care provided by Dr B were inadequate; there was a lack of documentation of her decision not to order compulsory treatment, risk assessment was inadequate, and sending Mrs A home from hospital after the second self-harm episode was also ill-advised.
He said the DHB had a duty to ensure that services were provided to Mrs A in a way that complied with the patient rights code. Instead, there was too much reliance on self-reports by Mrs A.
'Insufficient clinical assessments'
He also quoted advice he had received from an independent expert, psychiatrist Yvonne Fullerton, who said there were insufficient clinical assessments of Mrs A's situation and the factors leading to her first suicide attempt, or why she changed so soon after her admission to hospital.
Mr Allan said Dr Fullerton also considered that staff caring for Mrs A "did not appreciate the significance of Mrs A's two suicide attempts, and therefore did not assess her risk adequately".
He said both the DHB and Dr B breached patient rights.
RN C received adverse comment for not being clearer in her communications with RN D over how care for Mrs A was intended to be shared.
RNZ understands the Coroner is yet to conclude an inquiry into Mrs A's death.
Mr Allan said both Dr B and RN C no longer practised.
The DHB told RNZ it extended its sincere condolences to the family for its loss, and for the aspects of care by the DHB that were substandard.
It said it had implemented Mr Allan's recommendations, including by developing clearer guidelines around managing care among multiple team members.
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
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.