The South Canterbury District Health Board has been faulted over the care of a mental health and addictions patient who was later found dead at home.

Health workers and their employer have been subjected to official criticism following the death of a man who had mental health and addiction troubles.

The man, who had been a patient of the Timaru-based South Canterbury District Health Board, had harmed himself and threatened to take his own life. Some weeks after he was discharged from the DHB’s alcohol and drug service, he was found dead at home.

Deputy Health and Disability Commissioner Kevin Allan investigated and in a report issued today said the DHB had breached the code of patients’ rights. He also made “adverse comment” on two psychiatrists and a nurse.

“I am concerned that towards the end of [the man’s] care, emphasis appears to have been placed on dictating [his] behaviour, and support and guidance for staff were lacking.

“I consider that a more compassionate and consumer-focused approach could reasonably have been taken.”

The Health and Disability Commissioner legislation calls patients “consumers”.

Aged in his 40s, the man, unnamed in the report, had had a long history of mental health and addiction problems. He was first referred to the DHB’s mental health and addiction service in 1995.

Friends complained to the commissioner’s office about the care the man received in the months before his death.

He was admitted to a public hospital in 2015 after self-harming. He was diagnosed with adjustment disorder, alcohol dependence and antisocial personality disorder.

This began a three-month involvement with the DHB – and at times the Police – which included voluntary admissions to an acute psychiatric unit, and outpatient care.

On one occasion when he was discharged from the unit, a nurse recorded that the man continued to be a moderate to high risk in the community for harm to himself and others.

Allan’s report notes that the man had sent inappropriate text messages to a female worker at the alcohol and drug service.

At the multi-disciplinary team meeting at which the man was discharged from the alcohol and drug service, a risk assessment recorded that he was at chronic risk of suicide.

Allan said he acknowledged the needs of the man, ‘Mr A’, were complex and that he required support from both mental health and addiction services.

“However, it was the role of the South Canterbury DHB and its staff to provide Mr A with appropriate and adequate care, taking account of that complexity.”

He said that although individuals bore responsibility for some of the shortcomings in the man’s care, “overall I consider many of the failings exhibited in this case to be systemic issues for which SCDHB is accountable”.

Allan said the DHB had implemented professional supervision for clinical staff in the alcohol and drug service, in response to his earlier, draft findings.

His final report’s recommendations include making an assessment of mental health and addiction services and reviewing policies on staff sexual safety, incident reporting and the discharging of patients.

The Herald has sought a statement from the DHB.

Need help?
• Lifeline – 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP)

• Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)

• Healthline – 0800 611 116

• Samaritans – 0800 726 666

• Depression Helpline – 0800 111 757 or free text 4202 (to talk to a trained counsellor about how you are feeling or to ask any questions)

• Youthline – 0800 376 633, free text 234 or email

Source: NZ Herald


  1. This unfortunate fellow human being was diagnosed with ” adjustment disorder, alcohol dependence and antisocial disorder”. He was first referred to mental health services when about 20 and remained continually mentally unwell ever since (over 20 years). He now could not stand it any longer and “was found dead at home”
    Sorry guys, his diagnosis was wrong : he was suffering from human insanity (schizophrenia), a terrible genetically based mental condition with which one per cent of mankind will come down and from which only about a third will recover. People like that used to be protected in residential mental hospitals. As a society we should be eternally ashamed for leaving him to struggle on his own.


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