Mans death avoidable coroner
February 27th, 2008, 3:20 am Hobbies News
Kenneth Keen, 37, was found dead by his parents at his city flat on March 1, 2006.
Coroner Trevor Savage, who yesterday released his inquest findings, said Mr Keens death was avoidable.
If he had been visited by a mental health worker in the afternoon or evening of February 28, 2006, the day he had died, his illness would have been picked up, the coroner said. %26quot;He was not visited. Had he been visited there was a chance that medical treatment would have succeeded in saving his life.%26quot; The organisation looking after Mr Keen was PACT, a non-government organisation that provided support services to mental health patients under contract to the Southland District Health Board.
Mr Savage found that before Mr Keen moved into his Dee St flat, an agreement had been reached requiring PACT support workers to visit him three times a day, seven days a week, for seven hours each day.
However, they had failed to do so and on the day Mr Keen died a PACT staffer visited him just once in mid-morning. Mr Keen had what appeared to the staffer to be flu and he told his team leader and the community mental health team case manager.
Mr Keen was not visited again that day, Mr Savage said.
He died that evening of a combination of acute bacterial meningitis and diabetic keto-acidosis.
Various reasons had been given by PACT for not visiting him again that day. Mr Savage said the principal thrust of PACTs evidence had been Mr Keens visiting time was reduced to comply with his wishes.
A PACT review of its procedures after Mr Keens death had revealed deficiencies in the way notes were kept and information shared. The deficiencies had been fixed, he said.
Mr Savages findings recommended that the Southland District Health Board compile a template of information on symptoms of common types of physical illness mental health patients might suffer from.
These templates could be provided to PACT workers, he said.
PACT group chief executive Louise Carr and SDHB interim chief executive Brian Rousseau said the recommendation would be introduced in the near future.
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