Mental Health Commissioner Kevin Allan today released a report finding Canterbury District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for the care provided to a woman with mental health and addiction issues.

The woman was admitted to hospital following an episode of self harm; she had a history of anxiety and depression and daily alcohol use. She was reviewed by the Psychiatric Emergency Service (PES), which requested a referral to Community Alcohol and Drug Service (CADS). CADS understood that PES would be continuing to work with the woman with regard to her mental health issues. However, after PES was unable to make further contact with the woman she was discharged by PES and her referral to CADS was withdrawn.

The woman later spoke with CADS by telephone and was referred to the Alcohol and Other Drug Coordination Service (AOD), which organised an assessment for the woman in a few weeks’ time. However, the woman had no further contact with DHB services before she was found to have passed away.

Mr Allan found that DHB staff separated the woman’s mental health and addiction issues from one another which resulted in inadequate co-ordination of care by the DHB. He stated that this highlighted the importance of an integrated system of health care for consumers with co-existing mental health and addiction disorders. He made a number of recommendations for the DHB, including that it review and update its Service Provision Framework and apologise to the woman’s family.


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