Deputy Commissioner Dr. Vanessa Caldwell found that a District Health Board (DHB) breached Right 4(1) of the Disability and Health Services Consumer Rights Code (the Code) in relation to care of a man in his forensic mental health unit.
Dr. Caldwell felt that there was a lack of clear assessment and planning regarding the management of the man, who had been transferred to the forensic unit from prison, where he displayed agitated and aggressive behaviour. The man self-harmed while he was in the forensic unit.
Dr. Caldwell felt that it was unclear whether important information about the man’s risk level was being adequately communicated to nursing staff.
He also noted that for people experiencing acute episodes of distress, the relative risk of self-harm changes rapidly and frequently, as it did in this case. The deputy commissioner acknowledged that the DHB had a range of tools to assess and manage risk, but felt there was room to improve the way risk is communicated.
Dr. Caldwell recommended, among other things, that DHB provide an update on the changes it has made to risk assessment and communication, and provide a written apology to the man and his family.
Dr. Caldwell also wrote to the Ministry of Health to request support for the development of consistent risk management and safety planning protocols to replace the practice of risk prediction.
