WARNING: This article deals with mate whakamomori / suicide.
A young man in mental distress was never examined by a psychiatrist despite being admitted to hospital and later treated in the community for six months before his death.
The promising young sportsman died by suicide in 2017 after being repeatedly failed by Bay of Plenty District Health Board.
One expert has gone as far as labelling the lack of psychiatric input into the man's care as "astonishing".
Now his family hope a Human Rights Review Tribunal declaration released this month into the case will prevent other parents experiencing the anguish they have since losing their son.
In a statement released to Open Justice, Mr A's family said they wanted it known how deeply distressed they were to read of the repeated failure of Bay of Plenty DHB to adhere to accepted standards of practice.
"We are forced to live every day questioning whether this tragic outcome could have been prevented if the DHB, and our son's clinicians, had simply met their obligations to him and did their jobs correctly.
"We hope this report spurs positive change, and prevents other families from living with the pain and loss we still endure every day."
The declaration reinforces a Health and Disability Commissioner's [HDC] finding in May last year that the DHB failed to provide services to the man, known as Mr A, with reasonable care and skill.
The then Mental Health Commissioner Kevin Allan also found the DHB breached Mr A's rights by failing to co-operate with other healthcare providers to co-ordinate the man's care.
He referred the case to the HDC's Director of Proceedings who filed a claim in the Human Rights Review Tribunal.
Mr A first needed help for depression in his late teens in 2014, and again in 2015 after hallucinations and self-harming incidents following the use of recreational drugs.
He moved away to university but after a relationship break-up Mr A moved home to live with his parents and found outdoor work he enjoyed.
In August 2016 Mr A was admitted to a mental health ward after self-harming and his regular medication of Prozac was reduced to allow him to take the anti-psychotic Quetiapine to treat anxiety and insomnia.
A consultant psychiatrist who had primary care of Mr A did not examine him even though the DHB's policy at the time required all psychiatric inpatients to be seen by a senior doctor within 24 hours of admission.
He was not seen by a psychiatrist in the three days he was there, nor when he was discharged into the community, which the DHB said was unusual.
A multi-disciplinary team decided Mr A could stay an extra one or two nights on the ward for medication monitoring but he was discharged early and no-one could pinpoint who was responsible for that decision.
The discharge summary included a plan for Mr A to see the senior psychiatrist a month later but no-one told his parents and the appointment was missed.
After that the senior doctor wrote to Mr A explaining he was transferring his care to a psychologist Mr A had seen once, even though the policy was that a patient should only be discharged from care after at least two missed appointments.
It meant Mr A was never seen by a psychiatrist for his mental distress which continued until his death in March 2017.
The HDC's expert in its investigation of the case, consultant psychiatrist Dr Alma Rae, said it was a serious departure from accepted standards of practice.
"For a consultant not to have seen a patient who was in hospital for three days and then an outpatient for a further six months is astonishing."
The accepted standard of practice for patients in the community was for psychiatry review every three months, which the senior doctor failed to organise.
There was also criticism of the psychologist after Mr A's parents sought a private psychologist to help their son who they felt wasn't getting better.
However, she was going on annual leave and asked the original psychologist to continue seeing Mr A while she was away for two weeks.
He refused, saying it would be unethical and a conflict of interest to see another psychologist's patient but the Tribunal said the Community Mental Health Team should have continued to see Mr A, particularly because of indications he needed help, including his mother's ongoing concern for his wellbeing.
The DHB was also criticised after the psychologist and a nurse who were the most involved in Mr A's care, made up two of the four staff who undertook a serious incident review of the case after Mr A died.
Since Mr A's death the DHB said it had implemented changes to make sure the failings in care were addressed and both it and the senior psychiatrist apologised to the family.
Mr A's mother told Open Justice her son, who died four days after his 20th birthday, was a gifted sportsman who could do well at any sport he tried including rugby, surfing, and waterskiing.
"He was a daredevil. He was always the one doing the biggest manus off the wharf. But he was also very cuddly. He used to fix up boats, and he loved fishing.
"He was my middle boy. He was very smart at school. He had lots of friends.
"It's been a really hard, long road, all these reports; reading and re-reading. The guilt is just overwhelming."
WHERE TO GET HELP
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Vaka Tautua – Services offered in the languages of Samoa, Tongan, Cook Islands, Māori or English. Freephone 0800 OLA LELEI (652 535)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111
