The Health and Disabilty Commisioner’s report on the tragic death of a 50 year old man in Wellington Hospital makes interesting reading for Liaison Psychiatrists. The report focuses on the behaviour of the doctors and nurses concerned and the systemic problems that allowed them to happen. What is interesting is that the family were far more concerned about the attitude of staff to their brother who had a bipolar disorder and had recently been treated with risperidone for hypomania.

[Mr A] was an unassuming and gentle person, painfully aware of the views generally held by society towards mental-health consumers and the treatment that often resulted. The injustice and unfairness of this situation made him very sad, and after more than thirty years in the mental health system it was something he had become resigned to. During his stay in Wellington Hospital, [Mr A] told us on several occasions not to get a nurse or make a fuss as it would ‘just make them angry’. ...”

Our belief, based on own experience at this time and strengthened by your report, is that [Mr A’s] inability to co-operate, due to his deteriorating condition, led to him being labelled as a ‘non-compliant’ patient. That label, along with his history of mental health issues, led to a situation where many of the medical professionals involved in [Mr A’s] case seem to have down-graded the level of care they provided, based on their own prejudice and as a punitive measure against him for being ‘non-complaint’.

They felt that this was a reason why his agitation was minimised and he received a low priority. This doesn’t really come across in the expert comments which really just focus on what was recorded in the notes rather than interviews with the people concerned. This is a weakness in the report in that the way it is done makes it hard to say anything about attitudes.

Support for the culture of stigmatising patients with a mental health history comes from the DHB internal review, which comments on the need to “review smoke free policy to consider the needs of mental health patients in general inpatient areas”. Presumably this review won’t include patients who are not “mental health” patients (whoever they are). As one of the experts writes “this is to miss the point, it is not only ‘mental health’ patients who suffer while in hospital but any heavily addicted patient needs to have their needs addressed”.

The discussion on smoking is interesting. The issue was that the man was going through acute nicotine withdrawal for which he didn’t receive any effective treatment. (Presumably this wouldn’t be allowed to happen if he’d been withdrawing from alcohol). He wasn’t allowed to smoke on hospital premises and only received nicotine patches. His family brought in a nicotine inhaler in an attempt to control his withdrawal. The evidence appears to be that nicotine gum and inhalers are equally good at controlling acute withdrawal symptoms (DARE review).

According to the nurse expert there is an exemption in the 1990 Smoke Free Environment Act that allows hospitals to permit smoking in incapacitated patients. I couldn’t find it in the Act – anyone know where it is? Clearly according to this report there needs to be some flexibility in the management of incapacitated patients with a nicotine addiction in hospital.