1491899271262 - DHB, psychiatrist fail man who took his own life while in care

DHB, psychiatrist fail man who took his own life while in care

A young Dunedin man who took his own life while under a mental health service was given “sub-optimal” care, the Health and Disability Commissioner has found. 

Ross Taylor, 20, from Dunedin, received treatment from the Southern District Health Board (SDHB) mental health services in 2012 and 2013 for psychosis. 

A report by Mental Health Commissioner Kevin Allan was released this week, four years after Taylor’s parents complained to the Health and Disability Commission in June 2013.

Allan found the SDHB and a psychiatrist failed to provide services to Taylor with “reasonable care and skill” and to have breached the health and disability consumer rights code.

Taylor first sought help for psychosis after taking LSD and/or ecstasy at the Dunedin Hospital Emergency Department in 2012 at the age of 19.

He reported hearing voices and believed he had a device planted in his ear which was sending him messages. 

A few weeks later he was admitted to a psychiatric hospital after another presentation. For the next month he received treatment including anti-psychotic medication before being discharged to a community mental health service. 

At the time he was admitted Taylor said voices were telling him to kill himself.

Taylor was assessed to be “low risk” and not suicidal 12 days after being discharged by a community mental health service psychiatrist. 

Staff made a plan to reduce the anti-psychotic medication but neither Taylor or his parents were consulted about this.

The report outlines his deterioration, the growing desperation of his parents and their many attempts to have their concerns listened to. 

Three months before Taylor died he presented to another DHB emergency department while on holiday with his father and reported anxiety, hearing voices, poor sleep, and said he believed a microchip was in his ear, planted by his parents.

This was reported to the service in Dunedin but was not picked up as a clear signal he was relapsing. The plan to continue reducing medication continued.  

Allan found the service had not developed a relapse plan with input from Taylor and his parents and this amounted to “sub-optimal care”.

His recommendations included a review of processes for recovery plans; refresher education for staff on the treatment of co-existing disorders, an independent audit of documentation within the service and an apology to the family from the SDHB and the psychiatrist. 

A statement from the family said the last five years had been “heart breaking” and they were thinking about how their son and brother had suffered.

“Not a day goes by that we do not think that this could have been prevented if the care was not a significant deviation from expected clinical standards.” 

SDHB chief medical officer Nigel Millar apologised for the shortcomings in care Taylor received. 

“We extend our sincere sympathy to the family of this patient for their loss, and apologise for the shortcomings in the care he received from us in managing his condition.”

Millar said he was confident the recommendations would be implemented within three months.

Corinda Taylor

said early intervention could save lives and reaching out for help was essential. 

“When young men reach out for help it should always be taken seriously.”


Lifeline (open 24/7) – 0800 543 354

Depression Helpline (open 24/7) – 0800 111 757

Healthline (open 24/7) – 0800 611 116

Samaritans (open 24/7) – 0800 726 666

Suicide Crisis Helpline (open 24/7) – 0508 828 865 (0508 TAUTOKO). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.

Youthline (open 24/7) – 0800 376 633. You can also text 234 for free between 8am and midnight, or email talk@youthline.co.nz

0800 WHATSUP children’s helpline – phone 0800 9428 787 between 1pm and 10pm on weekdays and from 3pm to 10pm on weekends. Online chat is available from 7pm to 10pm every day.

Kidsline (open 24/7) – 0800 543 754. This service is for children aged 5 to 18. Those who ring between 4pm and 9pm on weekdays will speak to a Kidsline buddy. These are specially trained teenage telephone counsellors.

Your local Rural Support Trust – 0800 787 254 (0800 RURAL HELP)

Alcohol Drug Helpline (open 24/7) – 0800 787 797. You can also text 8691 for free.

For further information, contact the Mental Health Foundation’s free Resource and Information Service (09 623 4812).




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