Dear Capital and Coast District Health Board,

I write to you in my role as the Advocate of the deceased Samuel Jacob Fischer who was a patient of Te Whare o Matairangi psychiatric inpatient facility between January 31st 2015 to the time of his discharge to the Wellington Hosptial's Intensive Care Unit where he died on the 20th April 2015.

Under the provisions of the Official Information Act 1982, I request a copy of what was the standard 28 day staffing roster that was in operation for Te Whare o Matairangi's Te Taha Tauira and Whakatau Wairua wards during Mr Fischer's 2015 admission.

Additional to this base roster, I request the staffing records indicating names of staff, shift times and any shifts designated as overtime for those staff who worked on the Te Taha Tauira and Whakatau Waiura Wards between 31st January 2015 until 17th April 2015.

This information should be easily available and on hand and was referred to as being available by the CCDHB's lawyer at the ongoing Coronial Inquest into Mr Fischer's death.

I understand that a decision on a request for information under the Offical Informations Act 1982 should be made within 20 working days of receiving that request.

Yours faithfully,
Jak Wild
Advocate of the deceased
Samuel Jacob Fischer

Dear Robyn Fitzgerald [CCDHB],

Thank-you for your prompt reply

I would like to request that as this is in relation to a Sudden Adverse Event whilst under the care of CCDHB that due consideration is given to the CCDHB Open Disclosure policy in response to the request, particularly the clauses from the policy as follows:

1. POLICY AND GUIDELINE: OPEN COMMUNICATION (OPEN DISCLOSURE) Includes:-

Capital & Coast District Health Board (CCDHB) requires open communication with patients and their families as part of normal care and services. This includes when a patient suffers an adverse event whilst under the care of CCDHB. The process (including who leads the communication) relates to the level of harm. Initial communication should be as soon as practicable after the event is identified and information is to be provided in a planned way and a timely, open and honest manner.
Patients and their family/ support person can expect to be treated with empathy, respect and consideration including:

Acknowledgement of what has happened and an apology as relevant,
To be listened to and to have their feelings and needs taken into account,
To be given full and honest information of the known relevant facts and to have their questions answered where this is possible:
where harm has occurred, the known and expected consequences Where harm does not appear to have been caused or may not be immediately apparent e.g. gentamycin error, the known potential consequences, . .’

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Please forward an acknowledgement to Mr Nigel Fairley (General Manager, 3DHB Mental Health, Addictions and Intellectual Disability Services), for his 29.08.18 letter which I received the day of which was the deadline for his legislated obligation to respond to this Official Information Act (OIA) request, that being the 20th day after CCDHB received my request.

Please refer to my previous concerns noted in my latest communications regarding the OIA request for release of Mr Fischer's Electronic Health Record. I request the same consideration with this OIA, (i.e. greater transparency in communications from CCDHB by asking communications go via this fyi.org.nz website, and asking for responses to each OIA being specific and separate to prevent confusion, misrepresentation or diversion)

In reference to the aforementioned response from Mr Fairley to OIA's currently requested. For reference purposes below, at the end of this communication, I have appended and inserted the paragraph from Mr Fairley's letter, which is specific to the OIA request for Te Whare o Matairangi staffing records.

By way of an acknowledgement of CCDHB's contention of "concerns as to the privacy of staff outweighing other considerations which render it desirable, in the public interest, to make that information available". Can CCDHB re-consider the second part of this OIA request by designating an unidentifiable number for each staff member so by removing concerns as to privacy?

By way of an explanation as to the information that is requested being of public interest. The release of staffing records will facilitate investigation of documented evidence which shows either understaffing and/or mismanagement of safe staffing rosters during the admission period in which Mr Fischer died.

Evidence of understaffing and/or mismanagement of safe staffing rosters includes nurses working back to back shifts, including one instance two days before Mr Fischer died in which Mr Fischer's primary nurse worked three eight hour shifts in a thirty six hour period. This resulted in Mr Fischer's nurse having only an eight hour break (including travel time time to and from work) between the second shift which was a night shift ending at 2300hrs, and the third shift which was an early morning shift starting at 0700hrs. The timing of this concern was at a crucial point in Mr Fischer's treatment, and on the face of it breached the nurses duty of care provided to Mr Fischer.

The first part of this OIA request for the standard 28 day staffing roster that was in operation for Te Whare o Matairangi's Te Taha Tauira and Whakatau Wairua wards during Mr Fischer's 2015 admission does not include any privacy concerns therefore is requested to facilitate investigation and inquiry into Mr Fischer's death and is in the public interest as to the need for investigation of understaffing and/or mismanagement of safe staffing levels.

Please respond within the legislated obligations pursuant to the Official Information Act 1982.

Yours sincerely,

Mr Wild
Advocate of the Deceased
Samuel Jacob Fischer

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Appended letter received by email on 29.08.19 from CCDHB. Text specific to OIA request for:
Te Whare o Matairangi staffing records'
OIA request 2019-147 (CCDHB designated reference number)

Dear Mr Wild,

.....By email dated 7 August 2019, you submitted an OIA request for a copy of "the standard 28 day staffing roster that was in operation for Te Whare o Matairangi's Te Taha Tauira and Whakatau Wairua wards during Mr Fischer's 2015 admission". You also requested "the staffing records indicating names of staff, shift times and any shifts designated as overtime for those staff who worked on the Te Taha Tauira and Whakatau Wairua Wards between 31st January 2015 until 17th April 2015".
On 31 July 2015, you requested copies of staffing rosters throughout the period of Mr Fischer's admission to Te Whare o Matairangi and ICU under the OIA. We responded on 27 August 2015 refusing your request. In doing so, we noted that the names of the staff who cared for Mr Fischer were documented on the file.

We have again considered your request, and again refuse this request on the grounds that it is necessary to protect the privacy of those staff who were not involved in Mr Fischer's care. We have considered whether, in the circumstances of this particular case, the withholding of this information is outweighed by other considerations which render it desirable, in the public interest, to make that information available. We do not believe that any such considerations exist in this case, bearing in mind that this information has no relevance to the care of Mr Fischer.

For the same reasons, we also refuse the second part of your request....

Regards,
Nigel Fairley
MHAIDS

Dear Robyn Fitzgerald [CCDHB],

Please forward an acknowledgement to Mr Nigel Fairley (General Manager, 3DHB Mental Health, Addictions and Intellectual Disability Services), for his 29.08.18 letter which I received the day of which was the deadline for his legislated obligation to respond to this Official Information Act (OIA) request, that being the 20th day after CCDHB received my request.

Please refer to concerns noted in my latest communications regarding the OIA request for release of Mr Fischer's Electronic Health Record. I request that the same consideration be given with processing this OIA request, (i.e. greater transparency in communications from CCDHB by asking communications go via this fyi.org.nz website, and asking for responses to each OIA being specific and separate to prevent confusion, misrepresentation or diversion)

In reference to the aforementioned response from Mr Fairley to OIA's currently requested. For reference purposes below, at the end of this communication, I have appended and inserted the paragraph from Mr Fairley's letter, which is specific to this OIA request for; 'Te Whare o Matairangi staffing records'

CCDHB's contention for reasons not to release the requested information is stated in Mr Fairley's letter as being due to "the wide range of health professionals that were clinically responsible for Mr Fischer's care" and that "this is simply not feasible, and we therefore refuse this request on the grounds that the information requested cannot be made available without substantial collation and research"

By way of acknowledgement of CCDHB's contention for reasons not to release the requested information, please re-consider a significantly limited amount of information to be released. That being records solely related to the small number of staff who have appeared as witnesses on behalf of CCDHB in the coroner's court in relation to the death of Mr Fischer.

By way of acknowledgement of CCDHB's contention that "even if the request was limited in scope, we would need to consider the privacy interests of individual staff". Please re-consider a release of the information requested, based on the protections in place with the coroners non-disclosure order which I am bound by.

The information is sought to aid investigation and inquiry into Mr Fischer's death as well as in the pubic interest, due to evidence presented in the coroners court which indicates staff were not sufficiently competent in matters specific to suicidality, suicide, and risk management.

Please respond within the legislated obligations pursuant to the Official Information Act 1982.

Yours sincerely,

Mr Wild
Advocate of the Deceased
Samuel Jacob Fischer
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Appended letter received by email on 29.08.19 from CCDHB. Text specific to OIA request for:
'Request for Te Whare o Matairangi staffing records'
OIA request 2019-153 (CCDHB designated reference number).

Dear Mr Wild....

By email dated 8 August 2019, you requested:

1) Details of the training programs, modules, courses, competencies or other professional development provisions specific to SUICIDALITY, SUICIDE, and/or RISK MANAGEMENT, limited to staff who were clinically responsible for the late Mr Fischer during his TWOM admission between 31st January 2015 and 17th April 2015.

2} Details ofthe dates that clinically responsible staff completed such training as detailed in point 1 above, and details and dates of when any further training was required of said staff.

We note that a wide range of health professionals were clinically responsible for Mr Fischer's care during his TWOM admission between 31st January 2015 and 17th April 2015. Responding to your request would require us to review the records over this period, and identifying which staff were involved in Mr Fisch er' s care over the course of three shifts for each day of Mr Fischer's admission. This is simply not feasible, and we therefore refuse this request on the grounds that the information requested cannot be made available without substantial collation and research. In doing so, we have
considered whether fixing the charge or extending the time limit would enable the request to be granted, but do not believe that it would. We also note that, even if the request was limited in scope, we would need to consider the privacy interests of individual staff...

regards
Nigel Fairley
MHAIDS

Dear Robyn Fitzgerald [CCDHB],

Please ignore the last communications on this OIA for a request for TWOM staffing records. The communication was intended for the OIA requesting staff training records (2019-153 CCDHB designated reference number) which has been updated on the relevant OIA via the fyi.org.nz webpage

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Further to this request for release of ''Te Whare o Matairangi staffing records' for the purpose of transparency I reference here the latest response from CCDHB to this OIA request.

Please forward an acknowledgement of correspondence received 3.09.19 from Ms Iris Reuvecamp (Legal Counsel 3DHB Mental Health, Addictions and Intellectual Disability Services), who has now superseded Mr Nigel Fairley (General Manager, 3DHB Mental Health, Addictions and Intellectual Disability Services) in managing this OIA request.

In follow up to the release of staff records which the CCDHB had refused as detailed in previous correspondence, I refined my initial request to address CCDHB's grounds for refusal. This was by limiting the number of staff to those before the coroner court, addressing the privacy concerns by nominating a reference number so as to not identify staff, and limiting the time frame of records requested , so by addressing each of CCDHB's objections.

Ms Reuvecamps 3.09.19 response to my refined request was:
We will consider this request and will respond within 20 working days.

I will await the release of the requested information subject to the provisions of the Officia Information Act 1982.

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

I received a letter on 29.09.18 from Mr Nigel Fairley, General Manager, MHAIDS, declining this request for general staffing information on the following grounds:

We have considered whether it is possible to designate an unidentifiable number for each staff member so as to enable us to respond to your request while protecting the privacy of individual staff members. We do not consider that this is possible. Even it were possible, it would entail an enormous amount oftime and resource to de-identify this information in the way you suggest. It is simply not feasible to allocate such time and resource to responding to this request.

A challenge to this decision will be made via a complaint to the Ombudsman Office.

Pursuant to the Official Information Act 1982 I amend this request for a release of the following information:

1) Based on the Ministry of Health designated funding levels for nursing staff, please confirm how many Registered Nurses were required to be on duty in Te Whare o Matairangi's Te Taha Tauira ward and Whakatau Wairua wards on each of the 17th April 2015 shifts (i.e., AM shift (06.30-1500), PM shift (1500-2300), Night shift (2300-06.30).

2) The exact number of Registered Nurses working on each of the AM, PM and night shifts of 16th and 17th April 2015.

I remind you that when this information was unable to be provided to the Coronial Inquest in July 2015, Coroner Ryan informed me he was "sure this information could be released to me if requested from the DHB".

This information is clearly in the public interest, especially due to the evidence of understaffing at TWoM in April 2015. For example, contrary to New Zealand Nursing Organization safe staffing levels the registered nurse allocated to Mr Fischer on the day he died had worked three eight hour shifts in a thirty six hour period, which resulted in this nurse having only an eight hour break (including travel time time to and from work) between the second shift which was a night shift ending at 2300hrs, and the third shift which was an early morning shift starting at 0630hrs.

Please release this information at the very earliest so to to better inform a number of lines of enquiry and investigation into Mr Fischer's death

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Additional information has come to light requiring a slight amendment to this Official Information Act request as follows:

Point 2 of the request was:
2) The exact number of Registered Nurses working on each of the AM, PM and night shifts of 16th and 17th April 2015.

Please amend solely point 2 of this request whilst keeping the rest the same as follows:
2) The exact number of Registered Nurses who worked each of the AM, PM and night shifts of 14th, 15th 16th and 17th April 2015 in Te Whare o Matairangi's Te Taha Tauira ward and Whakatau Wairua wards

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for the 29.10.19 response from Nigel Fairley for the information which was requested. For the purpose of transparency and to aid others I have copied and pasted the response below,

Yours sincerely,

Mr Wild

____________________________________________________________________________________

CCDHB'sResponse:

1. The Ministry of Health do not designate funding levels for nursing staff. Our own staffing expectations for TWOM were/are as follows:

AM Shift
1 Clinical Co-coordinator
Tauira 5 RNs 2 MHSWs
Whakatau Wairua if open, it is staffed on a 1:1 patient staff ratio. There is always at least 1 RN present.
Manaaki is staffed with 3 RNs

PM Shift
1 ACNM who over sees both units Tauira 5 RNs and 1 MHSW Whakatau Wairua as above Manaaki 3 RNs

Nocte
1 coordinator
Tauira 2 RNs and a MHSW
Whakatau Wairua as above
Manaaki 1 RN and 1 MHSW

2. Number of RNs and MHSWs working in TWOM on 14-17 April 2015;

14/ 04/ 2015: AM RN - 11
AM MHSW - 5
PM RN - 10
PM MHSW - 4
Nocte RN - 5
Nocte MHSW - 3

15/ 04/ 2015 AM RN - 11
AM MHSW - 5
PM RN - 11
PM MHSW - 2
Nocte RN - 4
Nocte MHSW - 5
16/ 04/ 2015 AM RN - 9
AM MHSW - 6
PM RN - 11
PM MHSW - 4
Nocte RN - 4
Nocte MHSW - 5
17/ 04/ 2015 AM RN - 11
AM MHSW - 4
PM RN - 10
PM MHSW - 3
Nocte RN - 4
Nocte MHSW - 6

RN - Registered Nurse MHSW- Mental Health Support Worker

We trust the information we have provided meets your needs. As you are aware, you have the right, by way of complaint under section 28(3) of the Offi 1;:i aU nfdtmation Act 1982 to the Office of the
•.
Ombudsman, to seek an investigation and r(;lv i ew of any refusal to disclose information to you . Further
information about making a complaint can he found at htt p:/ / www.ombudsman.parli ament.nz/ make­ a-complai nt.

Regards,

Nigel Fairley
General Manager