Review into the Treatment and Management of a Mason Clinic Special Patient

Published online: 
16 September 2016

The Director of Mental Health Dr John Crawshaw commissioned an external review into the treatment and management of a Mason Clinic patient.

This was in response to a serious incident in November 2015 where special patient Mr Manjit Singh, who was under a compulsory care order, breached the conditions of his leave and attacked his former partner.

The review was led by Dr Nick Judson, Psychiatrist and David Niven, District Inspector for Mental Health. It was a comprehensive investigation involving interviews with Mason Clinic staff, Mr Singh’s primary caregivers in the community and his family.

Now that the judicial process in relation to the incident is complete, the Ministry of Health is able to release the review report.

Review findings and recommendations

The review essentially found that the existing restrictions on special patients were appropriate, but made recommendations on improving their local application. All recommendations have been accepted by the Ministry of Health and Waitemata District Health Board.

The review found that the single most significant factor contributing to the incident was the decision taken by Mr Singh to deceive his caregivers, by ceasing to take his medication and repeatedly breaching the conditions of his leave. The overall standard of clinical care provided to Mr Singh by the Mason Clinic was found to be of a ‘very high standard’.

As the incident was found to have occurred in the context of a series of unfortunate circumstances that are unlikely to be repeated, the report recommends no general tightening of special patient controls. Incidents of this nature are rare, and special patients on leave in the community are subject to strict conditions and monitoring.

The review found that good clinical care, sound clinical judgment and strong working alliances with families and community supports remain the appropriate basis for the safe management and rehabilitation of special patients.

Review follow up actions

The Ministry and the Mason Clinic are committed to actions to minimise the risk of similar incidents occurring in the future. The Ministry has updated its advice to forensic mental health services on special patient reviews and special patient recall from leave. The Mason Clinic has implemented several service developments in response to the review’s recommendations.

Withholding of parts of the report

Several parts of the report have been withheld to meet the obligations of the Official Information Act 1982.

Publishing information

  • Date of publication:
    16 September 2016
  • Ordering information:
    Only soft copy available to download
  • Copyright status:

    Third-party content. Please check the document or email the Web Manager to find out how to obtain permission to re-use content.

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