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A consultant psychiatrist, together with a specialist early intervention in psychosis service (EIPS), had been treating a young man who had alcohol, drug abuse and mental health issues. Those issues included a previous (first) psychotic episode for which he received compulsory treatment in 2012.
Over the course of 2012 the patient was regularly seen by the services. His use of antipsychotic medication was tapered off (at his and his parents’ insistence) and he continued to be assessed by the medical team (psychiatrist and nurses). This included the team seeking out signs or symptoms of relapse and suicidality. The team’s extensive medical notes recorded repeated consideration to whether the patient was suicidal and finding no such indications. In March 2013, the consultant psychiatrist and principal psychiatric district nurse conducted a home visit and completed a comprehensive assessment of the patient, again finding no indications of suicidal intent or psychotic symptoms.
Unfortunately, three days later the patient died by suicide.
From the immediate aftermath of death onwards, the patient’s parents made serious allegations against those involved in their son’s care. In respect of the consultant psychiatrist, the parents’ allegations included that he was willing to lie and fabricate evidence. Medical Protection became involved at an early stage in defending the consultant psychiatrist in respect of all complaints made against him over the next decade.
At first instance the DHB undertook an internal investigation into the patient’s death. It heard from people including the parents and the clinical team. The parents’ complaint even at this early time included allegations that the medical team had fabricated records of additional phone calls where the parents said they had conveyed their escalating concerns about their son in a way that was consistent with psychosis. The DHB’s investigation (as well as a subsequent investigation by the Health and Disability Commissioner) found no evidence supporting these allegations.
At an early stage, the parents made a police complaint alleging the psychiatrist’s care of the patient was so deficient that he ought to be liable for manslaughter. While ultimately the police declined to further investigate or charge any person, the investigation of this complaint paused other processes (such as the coronial process) for a considerable period.
The parents also made a complaint to the Medical Council of New Zealand against the psychiatrist. No further action was taken by the Council.
A complaint to the Health and Disability Commissioner (HDC) was also made by the parents. This process spanned 2013 to 2017. While the complaint was processed, the coronial process was again paused to enable the HDC to conclude its work.
The HDC’s focus was on quality of care. The HDC appointed its own expert psychiatrist. She reviewed various documents but had not been involved in the patient’s care and was not available for questioning or testing of her opinions. The HDC was reliant on her opinion in finding there were grounds on which the DHB and doctor had failed to provide services to the patient with reasonable care and skill. In the doctor’s case this was in one respect only; that the patient should have been made sufficiently aware of alternative treatments following his presentation to a different DHB in December 2012 during a holiday. It is notable that the coroner subsequently decided to place little weight on these findings, observing that the HDC’s expert had provided no reasoned response to further information provided via the HDC process by the doctor, and because the expert was not a witness at the coronial inquest so her evidence was untested.
The HDC’s Director of Proceedings elected not to take any action against either the DHB or the doctor arising from its findings. Despite this, following the HDC report, the parents commenced civil court proceedings against the DHB and consultant doctor in the Human Rights Review Tribunal. They alleged breaches of the Code of Health and Disability Consumers’ Rights by the doctor and DHB. They sought a $100,000 award of damages.
This tribunal process was then halted to enable the coronial process to proceed. As the death appeared to have been self-inflicted, the matter had been referred to the coroner at an early stage. With police and HDC complaints dealt with, the coroner could commence his role.
A coronial inquest does not determine criminal, civil or professional liability of any person. Its purpose is to determine the causes and circumstances of death. A coroner may also make recommendations. In 2018 the coroner heard from the parties about whether he should convene an inquest, in light of the various investigations and complaints that had taken place to date. In 2019 the coroner decided to hold an inquest on limited issues that he considered had not been determined fully by other processes. A key issue for the inquest was whether the patient had been suffering a relapse by March 2013 or whether his behaviour and presentation was explicable instead by his ongoing alcohol and drug problems. Later the coroner added, as an issue to be determined, the question of whether the psychiatrist’s last (home visit) suicide risk assessment of the patient in March 2013 was adequate.
Preparation for the inquest required a lot of effort, time and resources from multiple parties, lawyers, medical experts, court staff and others. The coroner made his own independent investigations, including ordering that ESR (Institute of Environmental Science and Research) undertake a re-running of toxicology testing of the patient’s blood samples some six years after death. Various witness statements were obtained and the full written record of the patient’s file was also before the court. The bundle of documents was over 2,200 pages long. The DHB and consultant had separate legal teams. Each was required to engage independent senior psychiatrists as expert witnesses. Their role was to review the volume of material in order to express their professional opinion about the issues for inquest. The court also appointed its own expert psychiatrist who attended court and provided his opinion.
Preparation was made more difficult by the fact that the patient’s parents were self-represented and regularly made serious allegations about the clinicians and other witnesses’ honesty and integrity. The parents, although assisted by a support person who was a lawyer, conducted their own legal case, were witnesses in their own right, sought to cross-examine other witnesses (and each other), and provided written and oral submissions to the court. The court also appointed a lawyer to assist the court. The lawyer assisting the court was involved in ensuring the parents’ evidence was admissible for the benefit of the court, and questioned witnesses and presented legal arguments.
The inquest hearing lasted for ten days in December 2020. What was said at the hearing occupied over 930 pages of transcribed evidence. Early in 2021, the patient’s parents sought to reconvene the inquest because they sought to cross-examine the court’s appointed expert, an opportunity they had declined at the first hearing. This request was granted over the objections of the other parties involved in the process, who demanded finality. The inquest was resumed in March 2021.
Over six months later, in October 2021, the court discovered new information that had not been disclosed to the court or parties – communications between the patient’s parents and the ESR scientists, around the time of death, where the parents had sought to challenge or change the expert’s conclusions about identification of drugs in the patient’s system at time of death. The parties had to further address the coroner on this matter.
Several months later, in April 2022, the patient’s parents sought to put in evidence a new toxicology report that they had obtained from an expert witness. It was a written report. This late request was granted. It further delayed the delivery of the coroner’s findings.
In June 2022, the coroner released his 121-page decision. In summary he concluded that the patient’s death was a suicide, that the patient had been intoxicated, and was not suffering a relapse of psychosis.
The coroner concluded that the psychiatrist’s suicide risk assessment of the patient had been appropriate. This followed the conclusions of all three expert psychiatrist witnesses who had jointly said that the assessment was comprehensive and adequate, and assessed all relevant points of a suicide risk assessment appropriately.
The coroner remarked that there was a discrepancy in the evidence between the patient’s parents and the clinicians. On important factual disputes, he preferred the evidence of the clinicians and in particular found the consultant psychiatrist to be an honest and reliable witness. The coroner remarked that his evidence did not contain inconsistencies and that he was willing to make concessions or entertain alternative theories where appropriate. The coroner found his evidence was entirely consistent with the contemporaneous written record.
In September 2022, following the coroner’s findings being released (and made public in August 2022), all aspects of this long running saga were resolved by the patient’s family discontinuing their tribunal proceeding.
acknowledge the assistance of the doctor’s legal team in composing this report