Damning review slates DHB leadership after two suspected suicides in four days

A damning review into a series of suspected suicides at a North Shore mental health unit has cited poor leadership and staff burn out and suggests the building’s physical design assisted patients to take their own lives.

The review also found other critical failures at He Puna Wāiora in Takapuna, meaning patients felt neglect, humiliation, stress and lack of respect, resulting in some losing hope and “giving up”.

Waitematā DHB has today apologised to grieving families whose loved ones died under its care, admitting their lives will never be the same.

“We are deeply sorry and we are committed to doing better,” Director of Mental Health Derek Wright said.

The DHB commissioned the independent review following two suspected suicides at the unit in the space of four days in May last year.

In one case, the worried foster family of Tamaki Heke warned staff he was suicidal just hours before the 24-year-old was found dead in his room. His death is a suspected suicide, an inquest has yet to be held.

The review was released today after more than a year of investigations. It makes a raft of recommendations to the DHB and wider health sector in a bid to prevent more needless tragedies.

“The review panel acknowledges that the unexpected death of a person that occurs during a hospital inpatient admission is a tragic event that causes immense distress to families,carers, and staff,” the report says.

“This is especially so where the person has died by suicide. We wish to extend our heartfelt condolences to the family and whānau of the people whose deaths led to this report being commissioned.”

He Puna Wāiora is a 35-bed adult inpatient mental health unit next to North Shore Hospital.

The review says that on May 12 last year “NB” was found dead in the ward.

Heke died four days later.

The external review was commissioned to examine the tragedies and the unit’s operation.

A draft of the report was also circulated to the families of two other Waitematā DHB mental health patients who died in suspected suicides.

The review was charged with investigating:

• the physical safety of the ward, including “ligature points” and possible solutions;
• clinical governance and identifying any deficits;
• clinical culture and care;
• oversight of the mental health leadership team;
• policies for communicating with families and responding to urgent concerns raised by whānau.

Lacking leadership

It found serious inadequacies with the unit’s leadership, which was labelled limited and inconsistent, lacking transparency, controlling and “unresponsive to issues and views raised by front-line staff”.

The review found the unit’s model of care was “not well articulated, focusing more on what staff roles are rather than how care is delivered … and reflecting a predominantly biomedical model of care”.

Patients and their families felt staff were overly reliant on medicating clients rather than treating their underlying problems, which often resulted in long stays or re-admissions.

“There was stigmatisation of long-stay people as ‘bed-blockers’.”

Families also felt there were “scant” recovery programmes or activities for patients, with activities such as the gym and sensory room often locked and unavailable.

They said it would be helpful to “find a way to give people some hope and give them some fun”.

Families and patients also cited disrespectful or incompassionate treatment by staff. They felt their input was often ignored, with staff seeing them a “distraction and a nuisance”.

“We consider that a consequence of these issues were feelings of hopelessness and helplessness for consumers, family and whānau, and, at times, staff,” the review said.

Families told the review they felt shut out of earlier investigations in the deaths. The lack of inclusion meant the reports contained “factual inaccuracies”, causing them additional distress.

The review identified no effective primary nursing system at the unit and said there was “strong evidence of dysfunction” between teams.

There was significant pressure on beds because of high demand and bed closures due to staff shortages.

Some staff were “overwhelmed” and burnt out.

The review said an audit of the physical building’s potential self-harm risks was completed before the two suicides, with areas for further work identified.

Completing that work was considered critical to the unit’s safety.

Unit protocols now required medical consultation before reducing the frequency of observations for at risk patients, and notifying family of any change.

The report said inpatient deaths by suicide were relatively rare, meaning even experienced staff had little experience dealing with such tragedies.

“Suicide contagion, in which a death by suicide or attempted suicide by one person is followed by suicidal behaviour by others in the same community … iswidelyrecognised,anddoesconstituteasignificantriskinan inpatientmentalhealthunit.”

Despite this risk the review found there was no document or protocol to guide staff following a suicide.

The deaths that sparked the review were “deeply regrettable”.

But the DHB had made considerable efforts to learn from the tragedies and take action to reduce the risk of similar events.

“There is, unfortunately, no way of completely eliminating such risk, but strenuous efforts have been undertaken, and are ongoing, to reduce it.”

The review makes a swathe of recommendations around strengthening leadership and culture, clinical care, and more focus on families and individualised care

“Inparticular,anyconcernsexpressedbyfamily and whānauaboutthe safetyofaconsumershouldbetakenveryseriouslyand respondedto with an appropriate clinical action.”

It also called for a wider review of specialist services for inpatient mental health clients, to ensure they received treatment for underlying conditions to prevent long stays in compulsory care.

Deepest sympathies

In a statement, the DHB’s Wright said the review was commissioned by the DHB immediately after the deaths “to gain independent insights” into how the unit was run.

He extended the DHB’s deepest sympathies and apologised to the families.

“We thank them for their courage in assisting the review and we also recognise that life will never be the same for them after the loss of theirlovedones.


“Wecannotturnbacktimebutwecanlearnfromthepastandmakechangesthatwillminimise the potential for inpatient deaths in future while recognising that it is impossible to remove all risk, as the report notes.”

TheDHBunconditionally accepted the reviewfindings and was committed to implementing them in full. Many had already been addressed.

“Wewelcomethescrutinyandweareproactivelyreleasingthereportbecausewebelieveonly goodwillcomefrom’lettingthesunshinein’.Althoughthereportisconfrontingin parts, we fully accept our duty to be accountable for our care, noting that He Puna Waiora is a different and safer unit today than it was in May 2019.”

Wright hoped sharing the report with other mental health services around the country would assist their ongoing improvement work.

He said the unit’s staff were highly motivated to help and care for others, and strived to do their best.

“We back our people to keep doing their jobs and will keep making the changes needed to support them to do so to the very highest standard possible.”

Where to get help:

• 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP) (available 24/7)
• https://www.lifeline.org.nz/services/suicide-crisis-helpline
• YOUTHLINE: 0800 376 633
• NEED TO TALK? Free call or text 1737 (available 24/7)
• KIDSLINE: 0800 543 754 (available 24/7)
• WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757 or TEXT 4202

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