David Macpherson – Nicky Stevens’ care was of a “good standard” – Yeah, Right.

For this Blog, I am writing primarily about how the Waikato DHB has handled the death of my son, Nicky Stevens, while a patient under compulsory care in their mental health unit, some 2 years ago.

However, Nicky’s story is, tragically but strikingly, very similar to dozens of other stories of death and harm caused to and by mental health patients, when so-called care organisations have ignored families, and ignored warning signs so obvious that Blind Freddy could see them.

Our family has been (I believe deliberately) outraged to see that the official DHB ’serious incident report’ has claimed – in its opening statement – that the care Nicky received “whilst in Henry Rongomau Bennett Centre was of a good standard”.

Nicky died while in the DHB’s care, after they were warned by the family (in writing and in meetings) of his high suicide risk if let out of the Hospital unsupervised.

The DHB’s response has after 2 years to produce a backside-covering report, clearly designed to justify the DHB staff and management actions, and inaction, that led to Nicky’s death.

Last week our family met with the DHB Chair, CEO and mental health boss, to “discuss the findings” and hear the DHB “offer an apology on behalf of the Waikato DHB for shortcomings in our processes”.

We told the DHB bosses we did not accept for one minute that allowing a patient, who had clearly demonstrated a high risk of suicide, to take unescorted leave on numerous occasions, against the wishes and pleas of his family and friends, suggests anything “good” about the standard of care provided to Nicky. No reasonable New Zealander would think that Nicky was well cared for by Waikato DHB.

We refused to accept their mealy-mouthed faux apology.

The family believes that, had their verbal and written requests for Nicky not to be given unescorted leave been followed, and had DHB management promises (to ensure just that) been actioned, Nicky would likely be alive today.

Despite the ridiculous claim that Nicky received a good standard of care from the DHB, their self-chosen review group have reported a long list of failings in Nicky’s care in the areas of:
• Inadequate and confusing patient risk assessment (the DHB Policy having expired over 2 years before Nicky’s death)
• A leave process and leave approvals that were contradictory and confusing to staff, management and family
• Inadequate and only partially followed procedures for handling the AWOL situation in Nicky’s case
• A lack of formal family involvement in Nicky’s care, despite his request that they be involved
• A lack of medication management and follow-up, plus evidence that he may have been on incorrect medication
How these failings can add up to a “good standard” of care is beyond the family’s comprehension, and suggests the DHB spin doctors have invented a Trump-like set of ‘alternative facts’.

To this list, the family adds:
• The failure for two years for the DHB to say “sorry’ to Nicky’s family for their part in his death
• A total lack of bereavement support provided to the family
• The arrogance and disdain shown towards the family by a number of senior DHB clinicians
• The lack of independence of any investigation into Nicky’s death
• The full state funding of legal representation for the DHB and its staff, and for the Police, at the coming Coroner’s hearing, while the family has to meet 100% of its legal costs, after the DHB refused to assist
• The disappearance of some key medical records from Nicky’s file
• Dangerously low staffing levels, including in Nicky’s Ward on the day he disappeared
• The failure of staff to record and pass on vital factual information relating to Nicky’s care
• The effect of the DHB’s blanket ‘no-smoking’ policy on HRBC patients, forcing them literally onto the street, regardless of the risk to them or the public
• Shoddy and non-existent security and safety procedures at the HRBC, including the ward Nicky was placed in
• Ineffective management and leadership in the DHB’s mental health sector (some of whom have since, tellingly, been removed)

The family is concerned that the Coroner’s Hearing relies on this inadequate ‘Serious Incident Report’ to form the backbone of its own investigation; and have already faced a request from the senior lawyer representing the Coroner to have no hearing at all, something the family has rejected in no uncertain terms.

They have no date yet for the Coroner’s Hearing – note that some families of suicide victims are waiting over 5 years for their hearings!

WHAT IS NICKY’S FAMILY AFTER?
1 The family wants a full and unequivocal apology from the DHB for their part in Nicky’s death – he was legally placed under their ‘inpatient’ care by one of their own clinicians, authorised under the Mental Health Act.
2 They want the DHB to fund their involvement at the Coroner’s Hearing to the same level as they are funding themselves and their staff.
3 They want a public acknowledgement from the DHB that there are serious problems with the DHB’s mental health service, which leads to a community-led action plan to fix it, in the Waikato and elsewhere.
4 They want their son and brother to be remembered for the light his death has shone on some of the shortcomings in the mental health system, and the steps taken to fix them.

This country’s mental health system is stuffed. People are being harmed, and are dying to the tune of 570-plus per year, while a silly little nonentity like health ‘minister’ Jonathan Coleman parades his unconcern on every occasion there is a new horror story.

Health bosses of all stripes are instructed to be in denial, even when they have evidence of serious system failures. At some stage their dam will burst, and we can only hope that many of them are swept away by it.

 

Dave McPherson is TDBs mental health blogger and a Waikato DHB Member-elect. He ran for office after his son was killed by the mental health system in NZ.