Rights Of Man Were Breached By Social Workers Says Deputy Commissioner 19HDC01187

A man’s rights under the Code of Health and Disability Services Consumers’ Rights were breached by two psychiatric social workers, said the Deputy Health and Disability Commissioner in a decision released today. Deborah James said the social workers’ actions represented a serious departure from the appropriate standard of care the man should have received.

The man lived with schizophrenia and was experiencing deteriorating mental health. After a suicide attempt, the man was taken to a police station for a mental health assessment. There, he was assessed by two psychiatric social workers.

A risk assessment form was completed but important information was missed such as his suicidal ideation and previous suicide attempts. The social workers also did not give appropriate weight to the fact of the man’s suicide attempt on that day, and they relied too heavily on the man’s self-reporting. Neither social worker consulted a psychiatrist, or other clinician, contacted the man’s wife or his other support worker, or followed the Health New Zealand guidance for safety planning.

They recorded him as a low risk to himself and others, developed an overnight safety plan which involved medication, refraining from drugs and alcohol, and calling the mental health crisis team if needed, and sent him home. The man took his life later that day.

The man’s wife complained to HDC saying he should have been taken to hospital and that he was three days overdue for his schizophrenia medication, despite requesting it. The social workers reported that although the man requested his usual injection for managing schizophrenia, they agreed this could wait and be done by a registered nurse the next day.

One social worker expressed the view that because of her lack of familiarity with the man, she had less responsibility at key parts of his care. Ms James stated "I remain of the view that, as she was present and assisting with the assessment, she could have acted at any point to remedy the failures identified."

Deborah James noted that the other social worker was a junior and said, "I consider that if Ms B did not have the requisite skills and training, once she recognised this while assessing Mr A, she should have sought further support, rather than continuing".

Ms James made an adverse comment about the clinical note taking of both social workers, and against Health NZ for issues identified in the report with resourcing and training of mental health staff.

Ms James’ recommendations acknowledged that considerable time had passed since the events and both social workers had undertaken significant extra training in their practice. She encouraged them to further reflect on the events and report back to HDC, including on any further training they have taken up, which they both did. She also acknowledged Health NZ had made several relevant and appropriate changes in its policies and procedures, so made no further recommendations.

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