A Dunedin poet died by suicide after his mental healthcare \u2018\u2018fell below appropriate standards in ways that contributed to his death\u2019\u2019, a coroner has found.<\/p>\n
Ian Loughran, 55, was found dead in his Opoho home by his wife on July 19, 2021.<\/p>\n
In May last year, Coroner Mary-Anne Borrowdale held an inquest, which uncovered multiple shortcomings in his care in the months before his death.<\/p>\n
After two admissions to Wakari Hospital for displaying manic behaviour, Mr Loughran was not properly followed up and was \u2018\u2018lost to care\u2019\u2019.<\/p>\n
He was not seen by any clinician for 24 days before he was found dead.<\/p>\n
\u2018\u2018Mr Loughran should have been supported in making his way back to wellness. Rather, he was left on his own to manage,\u2019\u2019 the coroner said.<\/p>\n
\u2018\u2018I have found there to have been significant failings in the delivery of care. These short-changed Mr Loughran and reduced his chances of recovery,\u2019\u2019 she said.<\/p>\n
And she warned it could happen again after an internal review by Health New Zealand (HNZ) found the ideal standard of in-person hand-overs was \u2018\u2018not achievable\u2019\u2019.<\/p>\n
\u2018\u2018This response provides no reassurance at all that what happened to Mr Loughran could not recur,\u2019\u2019 the coroner said.<\/p>\n
Mr Loughran\u2019s wife, Dr Andrea Insch, expressed significant concerns with the treatment and care of her husband, and her concerns formed the \u2018\u2018backbone\u2019\u2019 of the coroner\u2019s inquiry.<\/p>\n
Mr Loughran was a poet, well-known volunteer and award-winning stand-up comedian.<\/p>\n
He read his poems for audiences around the globe and wrote numerous plays, as well as hosting two radio shows.<\/p>\n
Between August 2020 and January 2021 he began experiencing \u2018\u2018manic and depressive highs and lows\u2019\u2019 and on February 10, was admitted to Wakari Hospital and diagnosed with bipolar disorder.<\/p>\n
A discharge plan was created and he was released from the ward five days later.<\/p>\n
The plan was abnormal because Mr Loughran had refused follow-up from a community mental health team, instead agreeing to receiving medication injections, seeing his GP and a private psychologist.<\/p>\n
HNZ guidelines dictate once a mental health patient is discharged, there should be a follow-up within seven days.<\/p>\n
But Mr Loughran did not attend that appointment and was uncontactable.<\/p>\n
Despite that, he was formally discharged from all mental health services.<\/p>\n
At the inquest, Mr Loughran\u2019s wife said he was \u2018\u2018basically being discharged into thin air because there was no-one who was really actively looking after him\u2019\u2019.<\/p>\n
A mix-up with the patient\u2019s paperwork meant he did not get the injected medication required to stabilise his mental state.<\/p>\n
The clinic which provided the medication wrongly believed it did not have the required information to complete the referral.<\/p>\n
In a 2022 explanation of events, clinic staff said: \u2018\u2018As the days and weeks passed, and there has been no communication to us, Ian Loughran\u2019s documents were filed away\u2019\u2019.<\/p>\n
The coroner said it was \u2018\u2018egregious\u2019\u2019 of the clinic to close the referral without notifying anybody.<\/p>\n
\u2018\u2018Given how essential and life-changing the [injected] medication can be – and the potentially severe consequences if a patient is unmedicated – it is inexplicable that the clinic failed to act on the prescription … sent through and simply \u2018filed away\u2019 [the] referral,\u2019\u2019 she said.<\/p>\n
The coroner found issues with Mr Loughran\u2019s discharge on this occasion \u2018\u2018amplified\u2019\u2019 his chances of relapsing and \u2018\u2018likely made a meaningful contribution to [his] death\u2019\u2019.<\/p>\n
She said too much trust was placed in Mr Loughran to follow the discharge plan.<\/p>\n
HNZ accepted errors had been made, but said the coroner was \u2018\u2018drawing a long bow to treat any of its acknowledged shortcomings in care as causes of death\u2019\u2019.<\/p>\n
In the weeks following Mr Loughran\u2019s first discharge, Dr Insch called Emergency Psychiatric Services (EPS) several times with concerns about her husband and they discussed whether she should invoke the Mental Health Act.<\/p>\n
The inquest heard Dr Insch found it \u2018\u2018profoundly distressing\u2019\u2019 to be made responsible for having her husband sectioned and wanted specialists to initiate that process.<\/p>\n
Mr Loughran was readmitted to Wakari Hospital on March 17.<\/p>\n
He had \u2018\u2018all the hallmarks of mania\u2019\u2019, was claiming to be a famous painter, a secret agent, the saviour of the yellow-eyed penguins and a millionaire.<\/p>\n
He stayed there until April 9, and again was \u2018\u2018lost to care\u2019\u2019 upon his discharge.<\/p>\n
His discharge plan on this occasion was agreed on similar terms, only this time Mr Loughran agreed to be seen by the community mental health team.<\/p>\n
A registered nurse spoke to him a few days after his release from hospital and later visited at his home.<\/p>\n
The nurse noted nothing of concern and told Mr Loughran a key worker would be assigned for further community follow-up.<\/p>\n
But no key worker was appointed.<\/p>\n
At inquest, the reason why could not be established, and HNZ described it as \u2018\u2018perplexing\u2019\u2019.<\/p>\n
\u2018\u2018In my assessment, clinical records misleadingly describe Mr Loughran as then going \u2018Awol\u2019 and \u2018avoid[ing] being seen by our services\u2019 after his discharge,\u2019\u2019 the coroner said.<\/p>\n
\u2018\u2018It would be more accurate to state that EPS avoided having any contact with Mr Loughran.\u2019\u2019<\/p>\n
Between April 15 and June 18, the community mental health team made no attempt to contact him.<\/p>\n
After calls to EPS from Dr Insch, they realised no appointment had been made since his discharge and on June 18 a registered nurse phoned Mr Loughran, who said he was managing well and had returned to work.<\/p>\n
Mr Loughran attended an appointment with psychiatrist Chris Wisely on June 25.<\/p>\n
Dr Wisely referred Mr Loughran to a registered nurse, who attempted to set up a meeting with the patient multiple times, but arrangements were interrupted by her scheduled leave.<\/p>\n
Dr Wisely said she could follow up once she returned.<\/p>\n
On July 17, Mr Loughran sent a text to his wife reading \u2018\u2018Love you so much xx\u2019\u2019 and she did not hear from him again.<\/p>\n
When Mr Loughran failed to attend a meeting two days later, the psychiatrist contacted Dr Insch, who called EPS.<\/p>\n
She was instructed to go to his home, but by then it was too late.<\/p>\n
The coroner made multiple recommendations which focused on addressing the gaps in Mr Loughran\u2019s care.<\/p>\n
\u2018\u2018After both of Mr Loughran\u2019s inpatient stays, his follow-up care derailed and was not delivered in accordance with discharge planning. There was no continuity of care, and each time a vital handover occurred he was cut loose of essential supports, who – in turn – were not aware that he had been dropped.\u2019\u2019<\/p>\n
She noted HNZ had conducted its own review following Mr Loughran\u2019s death and had made improvements in some identified problem areas.<\/p>\n
\u2018\u2018Health NZ accepts that … this inquiry highlighted a number of weaknesses in the processes of the mental health services, some due to resourcing issues and others to human error.\u2019\u2019<\/p>\n
But HNZ said many of the coroner\u2019s recommendations represented an \u2018\u2018ideal standard of care\u2019\u2019 which staff aspired to, but which \u2018\u2018cannot be consistently achieved given current staffing, funding and system pressure\u2019\u2019.<\/p>\n
2021 timeline<\/p>\n
February 10: Mr Loughran is admitted to Wakari and\u00a0sectioned under the Mental Health Act.<\/p>\n
February 15: He is discharged from the hospital and\u00a0considered autonomous.<\/p>\n
February 18: Mr Loughran does not attend a follow-up\u00a0appointment. His GP is advised \u2018\u2018a further appointment will\u00a0be booked\u2019\u2019, but it is not.<\/p>\n
February 19: Emergency Psychiatric Services (EPS) are\u00a0unable to contact Mr Loughran and decide to discharge\u00a0him as \u2018\u2018there was no indication of a relapse\u2019\u2019.<\/p>\n
February 26 to March 4: Dr Insch contacts EPS\u00a0repeatedly with concerns for her husband.<\/p>\n
March 17 to April 9: Mr Loughran is treated as an inpatient\u00a0at Wakari.<\/p>\n
June 25: Mr Loughran attends a scheduled appointment\u00a0with a psychiatrist.<\/p>\n
July 5: A nurse contacts Mr Loughran and arrangements\u00a0are made to follow up with him once she is back from\u00a0leave.\u00a0<\/p>\n
July 17: Mr Loughran sends a text to Dr Insch reading\u00a0\u2018\u2018Love you so much xx\u2019\u2019.<\/p>\n
July 19: Mr Loughran does not attend his scheduled\u00a0appointment with a psychiatrist and is later found dead at\u00a0his home.<\/p>\n
Recommendations<\/p>\n
\u2022 Health New Zealand should\u00a0implement its original plan to require\u00a0a clinician-to-clinician verbal\u00a0handover at the point of inpatient\u00a0discharge.<\/p>\n
\u2022 Enhance HNZ software\u00a0platforms so an alert is sent to\u00a0the responsible clinician advising\u00a0of a newly transferred outpatient.<\/p>\n
\u2022 HNZ should clarify guidelines\u00a0around who is responsible for\u00a0approving (if not drafting) each\u00a0discharge summary.<\/p>\n
\u2022 All information necessary for the\u00a0continuing care of the patient should\u00a0be documented in the discharge\u00a0summary.<\/p>\n
Need help?<\/p>\n
Healthline 0800 611 116<\/p>\n
Lifeline Aotearoa\u00a00800 543 354<\/p>\n
Suicide Crisis Helpline 0508 828 865\u00a0(0508 TAUTOKO)<\/p>\n
Samaritans\u00a00800 726 666<\/p>\n
Alcohol Drug Helpline\u00a00800 787 797<\/p>\n
General mental health inquiries\u00a00800 44 33 66<\/p>\n
Depression Helpline 0800 111 757<\/p>\n","protected":false},"excerpt":{"rendered":"A Dunedin poet died by suicide after his mental healthcare \u2018\u2018fell below appropriate standards in ways that contributed…\n","protected":false},"author":2,"featured_media":480559,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[134,527,111,139,69],"class_list":["post-480652","post","type-post","status-publish","format-standard","has-post-thumbnail","category-healthcare","tag-health","tag-healthcare","tag-new-zealand","tag-newzealand","tag-nz"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/480652","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=480652"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/480652\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/480559"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=480652"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=480652"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=480652"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}