If a Northland woman had been “properly monitored” by mental health services her death could’ve been prevented, a coroner says.

Kori Wharehuihuinga Hussey, 32, committed suicide in January 2019 after living what coroner Tania Tetitaha described as a “stressful and challenging life”.

Hussey was known to abuse alcohol and drugs, Tetitaha said, and toxicology results showed she had alcohol, methamphetamine and an antipsychotic in her blood when she died.

During her life, Hussey had moved between several mental health services across Auckland and Northland.

READ MORE:
* Coroner calls for hospital review after man sneaks out of ED, dies hours later
* Corrections, DHBs criticised for mental health care before prisoner’s death
* CDHB told to apologise to family of woman who died after substandard care

Tetitaha said this meant her care had to be transferred between multiple community-based providers and Hussey’s access to consistent healthcare depended on providers efficiently ensuring her care was transferred whenever she moved.

A report from Northland District Health Board (DHB) noted concerns about the transfer between Mid-North and Whangārei districts and the effect this had upon the standard of care Hussey received.

In Whangārei, Hussey was seeing a community mental health nurse, but there was no indication she was allocated a new one when she moved to the Mid-North area.

The reason why she wasn’t transferred was “unclear” as documents had noted Hussey had a “working diagnosis” of schizophrenia, on a background of meth and alcohol use.

The report noted there was a “lack of communication” between the services and the last noted contact with Hussey was in December 2017, more than a year before her death, with an alcohol and drug clinician.

Northland DHB’s serious event analysis report noted there was “ineffective support” and guidance for staff regarding case management and transfer of care processes increased the likelihood of her not getting the care she needed when moving.

Tetitaha said Hussey’s long-term addictions meant she needed a care plan monitored by one lead provider.

“It was imperative for her wellbeing to have a high level of communication between mental health providers.

“This may have ensured better follow up and engagement with her. If she was properly monitored by mental health services her ongoing addictions may have been better managed. It could’ve prevented her death.”

The situation had highlighted the defects in communication between mental health services and Tetitaha said there seemed to be a lack of protocols regarding transfers.

Tetitaha recommended Te Whatu Ora considered reviewing communications and processes for transferring between services. This included completion of a transfer plan and monitoring and auditing patient files.

Ian McKenzie, general manager of mental health and addiction services at Te Whatu Ora, accepted the findings and acknowledged the communication between services was “poor”.

“We are deeply sorry to her whānau that we did not provide the level of care she deserved. A number of improvements have been made following Ms Hussey’s death.

“This included development of more comprehensive referral and treatment pathways that support people who transfer across teams or geographical areas of Northland, as well as better communication and monitoring of patients.”