Photo: Supplied/ Office of the Health and Disability Commissioner
An investigation into the care of a person who was deemed unfit to stand trial and remanded in care has highlighted the lack of suitable facilities and trained staff for those with co-existing conditions.
In a report published today, the deputy health and disability commissioner found the person was injured when staff tried to restrain them, then wrongly placed in seclusion.
The health watchdog found Health NZ breached the code for care provided to the person who needed surgery as a result of the injury.
The person had been diagnosed with Fetal Alcohol Spectrum Disorder (FASD) and had a mild intellectual disability when they were remanded to the clinic in 2019.
They were sent to a forensic psychiatry medium secure unit despite having no history with mental health services, because there were no suitable beds in Health NZ's Forensic Intellectual Disability Secure Services.
Deputy commissioner Dr Vanessa Caldwell said it was concerning that the client who had specific vulnerabilities was not cared for appropriately and that staff did not seem to be trained sufficiently to take these needs into account.
It highlighted a lack of suitable facilities for people with co-existing conditions and the appropriately trained staff to provide care for them, she said.
"I have raised this matter previously with Health NZ, the Ministry of Health and Whaikaha and expect that as a system we can coordinate resources to better meet the needs of our most vulnerable."
The person was vulnerable and faced multiple challenges.
"The client's life had been unstable for a significant period and had been complicated by factors including substance abuse, living on the streets, involvement with the police, and a likely history of early trauma," the report said.
"Health NZ stated that while the client did not normally present with physical aggression, the risk of harm to self and others was known to increase when the client was in a vulnerable state."
The person's care plan included that additional support be put in place when the client is stressed and vulnerable to ensure safety of self and others.
"This included staff supporting and promoting the client's 'active engagement' to reduce the risk of dysfunctional behaviours such as deliberate self-harm," the report said.
"The client had been encouraged to approach staff if distressed or angry, and staff were told to prompt the client to use coping skills and/or have time out in their room or the library or be given courtyard access for exercise."
Health NZ said the client had told staff that when showing early warning signs of stress or anger, the best thing to do was to provide space and time alone.
Two years after being placed in care, in 2021, a lawyer raised concerns with the Health and Disability Commissioner (HDC), after the person was injured when clinical staff restrained them, then placed them in seclusion.
The report said the person in care had talked about self-harm, become increasingly angry and verbally abusive towards staff who asked them to walk to a high-care area to de-escalate.
"When the client declined to do so, the two staff attempted to put the client in an escort hold (a type of restraint) to guide the client to the high-care area.
"The healthcare assistant attempted to take the client's arm, and the client 'hit out at him'. When the registered nurse also tried to take hold of the client's right arm, the client 'hit out' and
knocked the nurse against the wall. Both staff then tried to take hold of one of the client's arms, and there was a 'significant struggle' and all three people fell to the floor.
A struggle ensued between the healthcare assistant, registered nurse, and the person in care who was injured when all three fell to the ground.
The report said the person in care's recollection differed, in that the healthcare assistant had "grabbed [me] by the arm and took [me] to the floor, then walked [me] through the main lounge, holding [my] arm behind [me] and twisting it".
The person was taken to the high-care area and into seclusion, where they remained for an hour then were seen by a doctor who confirmed an injury which later required surgery.
"I am critical that systemic issues culminated in the client being seriously injured during a restraint," Caldwell said. "Ultimately, Health NZ has an organisational responsibility to provide a reasonable standard of care to its residents. That did not occur in this case."
HDC found several failings in the care of the client, including a failure to employ de-escalation strategies and manage the client's restraint adequately, seclusion being initiated by healthcare assistants without the leadership of a registered nurse, and in breach of the seclusion policy, and a lack of documentation surrounding the events.
Caldwell said it is concerning that the client who had specific vulnerabilities was not cared for appropriately and that staff did not seem to be trained sufficiently to take these needs into account.
She said it highlighted a lack of suitable facilities for people with co-existing conditions and the appropriately trained staff to provide care for them.
"I have raised this matter previously with Health NZ, the Ministry of Health and Whaikaha and expect that as a system we can coordinate resources to better meet the needs of our most vulnerable."
Caldwell commended Health NZ for undertaking an adverse event investigation in a comprehensive and patient-centred manner and was satisfied that they had appropriately identified six broad areas where things went wrong.
However, she was concerned that some of the key improvements were not implemented in a timely manner.
Health NZ updated HDC on its progress towards implementing the recommendations a year after the recommendations were made, and two and a half years since the events.
The report said Health NZ did not contest the breach of the code and said that it had implemented "substantial service improvements".
