Canterbury Mental Health Services Inquiry Reveals Systemic Failings and Calls for Major Reforms

A comprehensive inquiry into Canterbury's Mental Health Services has uncovered 'significant' problems within the system, including critical staffing shortages, governance issues, and a 'siloed culture and care model.' The findings, released three years after the investigation began, have led to 18 recommendations aimed at addressing these systemic failures. The report has been met with strong reactions, including from the daughter of a woman murdered by a mental health patient last year, who called the system 'very broken.'

Staffing Shortages and Governance Concerns

Dr. John Crawshaw, the Director of Mental Health, launched the inquiry under section 99 of the Mental Health Act in June 2022 following the murder of Laisa Waka Tunidau by Zakariye Mohamed Hussein, a Hillmorton forensic mental health patient. The report highlighted 'critical staff shortages' in clinical areas, particularly in adult inpatient, community, and forensic services. Staff vacancies were affecting the admission and discharge processes, raising concerns about patient safety and the quality of care.

Dr. Crawshaw noted that the mental health services were 'not well placed' to meet the increased strain caused by a series of significant events, including earthquakes, floods, the Christchurch terror attack, and the ongoing impact of the pandemic. The report emphasized that 'the most significant and prevailing issue' was staffing, with many clinicians working overtime and double shifts to meet minimum staffing levels.

Culture of Blame and Safety Concerns

The inquiry also revealed a 'culture of blame' within the service, where staff were often discouraged from escalating issues due to fears of repercussions. Some staff reported feeling 'distressed' and 'angry' at the current state of affairs, particularly in the acute medium-secure unit, where a significant number of senior staff had left, affecting both numbers and expertise.

Frontline forensic mental health staff expressed 'significant concern' about their safety and the ability to provide a service. Some nursing staff were reportedly 'afraid to come to work' due to an 'unacceptably high rate' of assaults by patients. The report also highlighted the need for better integration of te ao Māori (Māori worldview) into the care model, especially given the cultural needs of the people accessing these services.

Recommendations and National Response

Dr. Crawshaw's 18 recommendations focus on three main areas: governance, care model, and resourcing. The report calls for better cooperation between leadership and service delivery, improved models of care, and long-term strategies for staff recruitment, training, and facilities. Health New Zealand (HNZ) has acknowledged the 'significant failings' and has committed to implementing the recommendations to 'prevent the tragic events of 2022 and 2024 from happening again.'

HNZ national director Phil Grady stated that the organization has already made 'demonstrable progress' on key recommendations, including establishing a clinical governance framework and increasing clinical staffing by 11% since 2022. However, the daughter of the victim, Karen Phelps, emphasized that the report confirms a 'very broken mental health system' and that more funding and action are needed to address these issues.

Call for Independent Inquiry

Following the release of the report, Chief Victims Advisor Ruth Money called for a Royal Commission of Inquiry into forensic mental health facilities. She argued that an independent inquiry would provide 'actionable expert recommendations' rather than multiple Coroners' inquests, which she believes lack the same binding influence. Money stated that the public and patients would be best served by an independent review, not another internal review that fails to bring about meaningful change.

Conclusion

The inquiry into Canterbury's Mental Health Services has exposed deep-seated problems within the system, from staffing shortages to governance failures. While HNZ has committed to implementing the recommendations, the call for an independent inquiry and significant investment in mental health services remains urgent. The tragic deaths of Laisa Waka Tunidau and Frances Anne Phelps serve as a stark reminder of the consequences of a failing mental health system. As the report calls for reforms, the challenge now is to ensure that these changes are not only made but also sustained to protect the public and improve the lives of those in need.