DHB - FAMILY INFORMATION RECOMMENDATIONS MADE BY CORONER TIM SCOTT The specific recommendation that I make is that the DHB develop a simple and brief written notice to families for all mental health patients advising in particular the name or names of the significant clinicians and case workers, their contact telephone numbers and, in particular, including their after hours numbers, and that notice to include a clear assurance that the DHB actually wants the family to engage the clinicians if there are concerns. Brevity and simple language is essential in such a notice for the notice to be effective. Such a notice should preferably be handed to the family representative and the handing should be recorded somewhere in the patient notes so that it can be referred to later if need be. If the notice cannot be handed to a family representative, it needs to be posted to a family representative and a record of that posting retained, and that needs to be done at an early stage in the treatment process. In addition to this, notices should in my recommendation, be prominently displayed in all areas where family members are likely to congregate. I make that recommendation, I leave it to the DHB to implement it and to hit upon the exact words. I say again that to be effective it needs to be concise and easy to understand. In my view more is seldom good and if a notice is a lengthy one and difficult to understand, people simply do not read it. The second recommendation I make relates to the incident investigation report prepared by Ms McDade. Counsel for the DHB, I think, conceded that that report was completed by an inexperienced author and was of limited worth as a tool to improve systems. That is my view, the report must have been produced to create a situation whereby the DHB could read and learn and, if need be, improve systems. I do not think that report, as presently drafted, without meaning in any way to denigrate from Ms McDade’s obvious sincere attempt to produce such a report, would do so. I recommend that that report be revisited by the DHB, but by a staff member of the DHB, not by an independent outside agency. I say that in particular because the DHB monetary budgets, as we all know, are limited. I think the best thing in general that a DHB can be doing with its funding is helping at the coalface to make patients better, whether physically or mental health wise. They do need to instruct outside agencies from time to time, but such instruction carries with it a level of expense, and I think it would be sufficient for this report to be revisited by a staff member of the DHB, and that is my recommendation. I now move to the issue of investigation by an inspector of Mental Health. I am not going to recommend that an Inspector of Mental Health conduct a separate enquiry, but I am persuaded that it may well be a good idea for an inspector to take a look at my findings and make up his or her mind whether a separate investigation ought to be undertaken by them. In part, I say that because they have claimed no particular expertise or knowledge, and what it is that such an inspector actually does or what such an inspector’s report is meant to achieve, I anticipate that it is meant to, again, make recommendations to make the system better, but I have no particular expertise in that field. So I leave it up to an investigator, his or herself, to make a call on whether to undertake a separate report. I have no doubt the counsel for the family will equate the relevant inspector with a copy of my decision, and I have no difficulty with that, and if the inspector feels that something good and useful could come out of a second investigation and report, then they will proceed with my blessing, but I do not go so far as to recommend that within the terms of the Coroners Act. nzlii.org/cgi-bin/sinodisp/nz/cases/NZCorC/2009/46.html?query=suicide
Posted on: Fri, 12 Jul 2013 05:53:36 +0000
Trending Topics
Recently Viewed Topics
© 2015