Canterbury mental health services slammed in new report after patients killed two people
The Section 99 'Inspection into Canterbury – Waitaha Adult Inpatient and Associated Mental Health Services', released today, was ordered to find out whether there were 'systemic issues' with the services.
Nine key findings were made.
The first was that the region's mental health services were struggling under the weight of 'accumulating legacy impacts' from earthquakes, the Christchurch terror attack, Covid-19, and a 35% prison population increase over the past decade.
Elliot Cameron was jailed for life for murdering Faye Phelps in 2024. It was not the first time he faced a murder charge - he shot and killed his brother in 1975 but was found not guilty by reason of insanity. Photo / George Heard / Supplied
The events had 'heightened demand for services' and caused long stays for patients due to ongoing impacts on housing, blocking community reintegration and delaying admissions.
Critical staffing shortages were the most significant and prevailing issue, the report found, with daily struggles to maintain minimum safe staffing levels across adult inpatient, community, and forensic services.
Forensic mental health services faced particular challenges, with concerns over an imbalance in the junior to senior staff ratio that could lead to safety risks.
Hillmorton Hospital in Christchurch. Photo / George Heard
Bed closures, early discharges, and reduced interventions have followed, causing re-admissions and pressure across the care continuum.
Staff morale was described as poor, with reports of burnout, 'a culture of blame' and 'significant disruption to staff learning and development'.
Mandatory training and clinical supervision had been cut back, worsening morale and compromising safety.
A 'siloed culture and care model' impeded cohesion between disciplines, while the incorporation of te ao Māori remained inadequate, the report found.
Another key finding was ineffective governance, with clinical governance described as reactive and focused on 'immediate issues at the expense of longer-term stewardship'.
Escalation processes were said to be difficult, and quality and safety data were poorly integrated into frontline teams. Regional leadership had delayed decisions on business cases aimed at fixing staffing and seniority gaps.
Recommendations focused on three main areas: governance, care model, and resourcing, with a goal of better co-operation between leadership and service delivery so staff can 'do their best' and plan for the future. They included:
Governance must prioritise and focus on forensic mental health service performance by fixing staffing/vacancy issues and putting in place a multidisciplinary model of care.
The link between service and regional leadership teams must be stronger with clear processes for making decisions, sharing information, and dealing with problems.
Leadership should build a culture based on 'servant leadership' and 'just culture,' which means 'shared accountability' and 'open and honest reporting'.
Māori cultural support should be fully part of the service, not an 'add-on', and a senior Māori health leader should support the Māori mental health team and make sure there is a 'collective Māori voice at the leadership table'.
It was further recommended that all staff should be involved and valued and make it clear that 'bullying in all forms is unacceptable'.
Serious incident reviews also need improvement.
Zakariye Hussein murdered Laisa Waka Tunidau in 2022 and was later convicted. Photo / George Heard
The decisions around patients getting leave into the community have also been 'significantly improved', Grady said, with independent weekly audits of all leave decisions now taking place.
Both Grady and Crawshaw met with Laisa Waka's family yesterday, a meeting Grady said was one of the hardest he's ever experienced.
'They have been through significant trauma and are still trying to understand the events and what happened.
'I am deeply sorry these events have occurred,' he said.
Health New Zealand says it is 'committed' to implementing the report's recommendations to try and 'prevent the tragic events of 2022 and 2024 from happening again'.
'We recognise the loss and grief these families have and continue to experience and express our sincere condolences to them,' said Grady.
'We are deeply sorry for the failings in our systems.
'We have reached out to these families to apologise and discuss Dr Crawshaw's report, and will remain in contact, if that is their choice, to update them on progress to implement actions from the report.
'We accept all of Dr Crawshaw's findings and have an action plan in place to implement the recommendations, which focused on the underlying issues related to governance, the care model, and resourcing.'
Health NZ National Director, Mental Health and Addictions Service Enhancement Phil Grady (left) and Ministry of Health Director of Mental Health Dr John Crawshaw. Photo / George Heard
Grady said Health NZ is focused on giving senior leadership oversight of planning for the service, building a framework, and 'ensuring there is sufficient staff with the right level of training and experience to safely and effectively deliver services'.
As noted in the report, Health NZ said there has been 'demonstrable progress' on key recommendations, including establishing a clinical governance framework and increasing clinical staffing by 11% since 2022.
Clinical decision-making on patient leave is now consistent with policies, Grady said, and there are weekly audits of compliance in place.
'There are clear pathways both within the service and nationally within Health NZ to escalate and manage risk,' he said.
'To ensure progress of the recommendations continue, we welcome Dr Crawshaw's increased oversight of the service over the next 12 months.
'We are committed to improving the service and our actions will be closely measured against this report, and two other event reviews conducted by Health NZ.'
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