A formal regulatory inspection of Canterbury-based mental health services has set out a series of recommended changes for Health New Zealand and is continuing checks over the next 12 months.
Ministry of Health Director of Mental Health Dr John Crawshaw, who undertook the inspection under Section 99 of the Mental Health Act, acknowledges the tragic circumstances prompting this work.
He expressed his deep sympathy for the family mourning the loss of Laisa Waka Tunidau who was murdered by a patient on community leave from Christchurch's Hillmorton hospital in June 2022. The Ministry's inspection began the following month in July 2022.
Sadly, there was a second tragic incident in 2024 involving a patient under the care of mental health services at Hillmorton - underscoring the urgency of addressing underlying issues facing the Canterbury service.
Dr Crawshaw says the circumstances of both incidents were separately investigated by Health NZ and are not directly covered by the Ministry's report, which looked more deeply into the underlying issues related to governance, the care model, and resourcing.
He says the report recognised the difficulties for mental health services brought by COVID-19 during the pandemic on top of a legacy of events in the region that have stretched mental health services and exacerbated existing systemic issues, and the findings of the review should be seen in that light.
Dr Crawshaw says the goal of mental health services is to support, care for, and treat individuals affected by serious mental illness to keep both them and the community safe.
Where there are serious service failures, such as in this instance, the legislation provides significant investigative powers to find causes, make recommendations and then monitor progress.
The report makes 18 recommendations covering governance, the care model, and resourcing. The overall theme of the report is the need for better cooperation between service leadership and service delivery to prioritise service, enable staff to do their best, improve the models of care, and planning.
"There have already been significant improvements made by Health New Zealand in many areas."
Dr Crawshaw notes that the use of leave plans and leave protocols have been assessed and updated following an independent review.
Safeguards now include a detailed leave procedure, an updated safety and risk assessment framework for leave, an amended missing person policy, and a review of the electronic clinical record system.
As of next week, for patients under the Mental Health Act who are cared for in Hillmorton's forensic services (but are not special patients), all leave requests, which follow a very robust, carefully considered process, will also require final review by the Director of Mental Health. This arrangement will be in place while the report's recommendations are being implemented.
Dr Crawshaw says Health New Zealand's work in quality improvement and progressing the report's recommendations will be carefully monitored over the next 12 months.
He says this will help provide the public with a stronger degree of assurance that underlying issues are being addressed and progress continues to be made.
The report can be found on the Ministry of Health website.
