A young woman rushed to Waikato Hospital after a suicide attempt absconded from the emergency department twice within an hour, breaking her ankle the second time.

Her mother has slammed the hospital after it admitted several failures on the day. She is calling for major changes to better protect vulnerable patients in similar situations.

The case has also highlighted the need for a “one-stop shop” national portal for patient information so medical staff in emergencies have all relevant information when treating a person.

There is currently no such system in New Zealand.

Kiri (not her real name) was taken to Waikato Hospital by her brother in early 2022 after a suicide attempt.

He advised staff that she had a history of previous attempts and several compulsory hospital admissions under the Mental Health Act in Auckland and Wellington.

For the first few hours she was in the emergency department, Kiri was primarily sleeping and waiting for a mental health assessment.

Thinking she would be safe, her brother told staff he was leaving but asked to be contacted as soon as she woke up.

By 2pm Kiri was fully awake and, 10 minutes later, staff noticed her bed was empty.

A short time later she was found outside having a cigarette and was taken back to the emergency department.

A nurse documented that she might need a “mandatory care partner” – someone to be with her at all times. However, no steps were taken to arrange this.

At 3.15pm Kiri left her bed again.

She later told her family she had heard the crisis team was coming and she took off because she did not want to be “locked up” again.

Waikato Hospital has admitted several failures in care on the day Kiri absconded twice. Photo / NZME

Hospital staff said “multiple” searches failed to find Kiri.

They told her brother and filed a missing person report with the police.

Kiri’s brother and uncle searched for her and found her not far from the hospital, lying on the ground with an ankle fracture.

She was taken back to ED and her brother agreed to stay with her until her assessment.

By 5pm a security guard had also been stationed outside her cubicle.

About two hours later, the crisis team assessed Kiri and said she had “chronic suicidal thoughts”.

She was discharged into mental health respite care, with the support of her family.

Her mother decided to speak out about her experience after reading the Herald’s coverage of Samara Visser’s death in 2019.

Visser took her own life after absconding on a walk with a nurse from a mental health unit at Auckland Hospital.

“Kiri could have ended up like Samara … and there are many other people who have absconded and taken their life - which is just tragic when it could have been avoided,” Kiri’s mother said.

“They need to do more to take more care of vulnerable patients. I don’t want this to happen to anyone else.

“This was not our first rodeo. We’ve been in the system a while but what happened at Waikato, I’ve never seen anything quite that poor.

“Letting someone just walk out of there when they were on notice that she had attempted suicide multiple times before – there are just no words.

“My daughter is probably still lucky to be here, and you shouldn’t have to feel ‘lucky’ when you’re dealing with the health system.”

Samara Jade Visser died after absconding while on a walk with a nurse outside an Auckland mental health unit. A coroner has released findings on the case. Photo / Facebook

In March last year, Kiri’s mother made a formal complaint to Waikato Hospital and this month shared both it and the response with the Herald.

“We are appalled, angry and deeply concerned as a whānau at the gross lack of care, respect and services provided to [Kiri],” she said.

“Given the nature of her admission for attempted suicide [Kiri] should have been under constant observation to prevent her from further injury or from any further self-harm.

“We would have expected after the first incident, there would have at least been stronger measures put in place to ensure she didn’t leave a second time.”

Kiri’s mother was “extremely concerned” and asked that both the Waikato DHB (now Te Whatu Ora Health New Zealand Waikato) undertake a full investigation.

“In particular, how could a mental health patient, admitted for attempted suicide, just walk out the door undetected on two separate occasions.”

She hoped that as a result of her complaint, and by speaking to the Herald changes would be implemented to ensure other mental health patients in the future would “receive the care and services they need and not come to further harm while in hospital care”.

The head of ED at Waikato Hospital sent an initial response apologising for the “distress and suffering” experienced by both Kiri and her whānau.

She conceded that, after Kiri absconded the first time, a mandatory care partner should have been organised.

“Unfortunately, that did not occur during her ED stay.

“We are very sorry for this oversight. This is inconsistent with the expected standard of care for our mental health patients presenting with overdose.”

Kiri left her hospital bed the first time to have a cigarette outside. Photo / File image

In a second letter after the investigation, the ED head said discussions had been held “specifically” around ensuring that, when a care partner was not available, the matter was “escalated” so that another healthcare assistant or security could be provided.

She said that, as a result of the investigation, “a number of areas” had been identified where improvements in care could be made.

“Additionally this has prompted us to review our policies on care for those admitted following self-harm, care of vulnerable patients and the process around patients who unexpectedly leave an inpatient setting.

“In [Kiri’s] case it is clear that, while the policies contained the right information, there were systems failures that have been urgently addressed.”

The ED head acknowledged Kiri’s previous medical history but indicated staff at the time of the admission had no information except that given by her brother.

“Waikato DHB does not have access to mental health records from other DHBs,” she said.

Kiri’s mother has also complained to the Health and Disability Commissioner, who has completed an assessment of the case and is now considering what next steps may be taken.

The Ministry of Health declined to comment on information access and sharing, deferring to Te Whatu Ora.

Kiri managed to abscond twice in an hour from Waikato Hospital's ED. Photo / Alan Gibson

After four full working days, a response was provided by Chris Lowry, Te Whatu Ora’s director of hospital and specialist services for Te Manawa Taki, an area covering Bay of Plenty, Lakes, Hauora Tairāwhiti, Taranaki and Waikato.

She said the comment made to the woman’s mother about DHBs accessing records was “not fully accurate”.

“All Te Whatu Ora facilities within the Te Manawa Taki region are able to access a shared digital patient record platform to view patient information across districts.

“This shared patient management system does not currently extend outside of the region.

“This does not prevent access to patient information for those who have been treated in another region. Clinicians will contact the ‘home’ district to request sharing of this information and can receive the relevant information rapidly.”

Lowry said there was an intent to better share patient information in future.

Last year the network of 20 DHBs was replaced by public health agency Te Whatu Ora.

“Part of the shift to a more integrated national health system will ensure our IT systems are joined up, to make sharing patient information [is] easier across the motu,” Lowry said.

SUICIDE AND DEPRESSION

Where to get help:
• Lifeline: Call 0800 543 354 or text 4357 (HELP) (available 24/7)
• Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: Call 0800 376 633 or text 234
• What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
• Depression helpline: Call 0800 111 757 or text 4202 (available 24/7)
• Helpline: Need to talk? Call or text 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.