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Waikato DHB concludes review into the death of Nicky Stevens

Waikato District Health Board has concluded the review it commissioned into the death of Nicky Stevens who died after failing to return from unescorted leave from the DHB’s mental health inpatient facility Henry Rongomau Bennett Centre, on 9 March 2015.

Nicky was admitted to HBRC under the Mental Health Act on 19 February 2015 after becoming unwell. A comprehensive risk assessment had concluded that Nicky’s risk level was low, and staff were committed to supporting Nicky in his recovery. Nicky was showing signs of improvement, he’d completed the majority of his periods of leave without incident and was getting ready to be discharged.

The review found that while the standard of Nicky’s care was good, there were a number of opportunities for improvements to how the unit managed clients’ leave and how it involved families in their loved ones’ care.

The review was delayed pending the police investigation which concluded last year and confirmed that police will not be prosecuting the Waikato District Health Board, or any individuals, over the circumstances surrounding the death of Nicholas Stevens.

The report made five recommendations, all of which have already been implemented or are underway, by the DHB and are regularly audited. The recommendations and the DHB’s response to these are:

1. Strengthening the leave management procedure to give clarity on the approval process and key responsibilities for the approval of leave.
• Confirmation of the documentation required for approval and recording of exit and entry times for everyone.
• A clear process in place detailing actions that must occur should a person not return within the agreed timeframe.

2. Strengthening of the AWOL (Absence Without Official Leave) procedure including a clear search process and regular simulation exercises for all staff.
• Any AWOL event is subject to immediate debrief and audit to ensure appropriate actions continue to occur.

3. Improving the AWOL notification process with police
• This has resulted in the inclusion of detailed risk assessment information in contact with police and agreed escalation process based on those levels of risk.

4. Strengthening the process for family consultation.

5. Ensuring greater collaboration with family/whanau.

• All admissions now result in a Circle of Care meeting that is inclusive of key supports for the person to ensure a comprehensive care and discharge plan. These supports are often family/whanau members, but can include clinical supports and key community networks.

The review was carried out by a team led by the DHB’s Director Quality and Patient Safety, Mo Neville and included an independent consultant psychiatrist from Australia and an independent lay person. She was appointed at the suggestion of the family. Nicky’s family were also involved in the review process.

Waikato DHB Chief Executive Dr Nigel Murray said: “The death of Nicky Stevens is a terrible tragedy and I would like to apologise most sincerely to Nicky’s family for the omissions in our leave processes while Nicky was in our care. Our management of leave was unsatisfactory, and I also acknowledge that the family would have valued greater collaboration.

“They can be reassured that there has been a lot of work done since 2015 to improve our inpatient mental health and addiction services. We are particularly keen to ensure that our services recognise the legitimate place that families have in decision-making around their loved ones.

“I’d like to thank everyone who participated in this review including the external reviewers, the family and our staff who were committed to this process and to learning from it.”

Dr Murray said: “Myself, the Board Chair Bob Simcock and the Director of Clinical Services of Mental Health and Addiction Dr Rees Tapsell are meeting with Nicky Stevens’ family today to discuss the outcome of this review and to extend our deepest condolences to them as we know this has been a lengthy, painful process. This review has provided opportunities for service improvements.

“We gave a copy of the report to the family at the end of last year, and while, at the time they declined our offer to make the report or its findings public, we are pleased that it is now in the public domain. The report has been sent to the coroner.”

Waikato DHB Clinical Director of Mental Health and Addiction Services, Dr Rees Tapsell, said: “People who are recovering from acute psychosis are often susceptible to very significant changes in their mental state which are not predictable despite the most thorough risk evaluation.

“Leave is an important part of the rehabilitation process and a necessary step towards recovery and discharge. It enables the clinical staff to observe how clients manage themselves, including their ability to show daily living skills and interacting with others.”

The final report is available here.

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