The Commissioner has found both a psychiatrist and a DHB in breach of the Code for various documentation, communication, and service coordination failures in the care of a community mental health patient who committed suicide.

The psychiatrist who attended the patient shortly before his suicide was found in breach of the Code for failing to adequately document his assessment and the patient's crisis plan before the psychiatrist left to go on leave. The Commissioner noted that his handwritten notes were "insufficiently clear to be meaningful" and criticised the psychiatrist for not communicating the crisis plan to the patient's general practitioner, the urgent community team, or to the patient's partner. The DHB was also found in breach of the Code for failing to ensure adequate communication and coordination between the various limbs of the mental health service. For example, the DHB had not ensured there were clear processes for assigning case managers and had failed to ensure good communication between the service and the patient's partner, or between the psychiatrist and the urgent community team. The Commissioner also made adverse comment about the registered psychiatric nurse involved, noting that while there was some confusion about whether the nurse was the formal case manager, the nurse should have "taken the initiative" to ensure the patient had appropriate support. 10HDC00805