Dear Capital and Coast District Health Board,

Further to emails you will have received to the CCDHB Quality Assurance Department dated 9th January 2015 and 8th August 2019. please assist me with the following within your obligations under the Official Information Act 1982

For the assistance of ongoing Inquiry and investigation into the death of Mr Samuel Jaoob Fischer can you please assist with the following:

1) Confirmation as to the correct Client Pathway layout document for Te Whare o Mataarangi's (TWOM) paper filing system that was in operation between January 31st 2015 and April 2015, which was the time of the late Mr Samuel Jacob Fischer’s TWOM admission. NB: Two very different and contradictory official documents have been provided to date for this period. Copies of these documents were attached to the 8th August email to the Quality Assurance Department to assist your investigation and response.

2) Please confirm which specific sections and documents were a mandatory requirement to be included
a) within the TWOM paper file
b) within the TWOM electronic health record

3) Can you please provide any additional CCDHB Client Pathway Procedures. Manual or policy relevant to the requirements for management and collection of health information for:
a) Mr Fischer's electronic health record (for which I am awaiting release)
b) Mr Fischer's paper file (which has already been released)

This request is subject to CCDHB's Open Disclosure policy that was in place at the time of Mr Fischer’s death, and subject to any relevant legisaltion such as the Official Information Act 1982, the Health Act 1956 and any other relevant legislation.

Yours faithfully,

Mr Wild
Advocate of the Deceased
Mr Samuel Jacob Fischer

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 which is specific to this OIA request for; 'Client pathway policy and procedure for Te Whare o Mataarangi electronic health record and paper (hard copy) file'

In response to point 3 of this OIA request Mr Fairley has requested I confirm that the "information I require relates only to the requirements which applied at Te Whare o Matairangi for the period 31 January to 17 April 2015"

I can confirm my request is for information that relates to the requirement (i.e. CCDHB hospital wide policy and procedures and any other health standard) which applied to Te Whare o Matairangi for the period 31 January to 17 April 2015.

I will await a response to Point 3 of this OIA request prior to responding to Mr Fairley's contentions as to Points 1 and Points 2 of this request.

The information is sought to aid investigation and inquiry into Mr Fischer's death as well as in the pubic interest, based on the findings of the Health and Disability Commissioners report into Mr Fischer's death, which found that CCDHB breached Rights 4(5) of the Health and Disability Code of Rights which were failings that the Health and Disability Commission considered had a potential to impact on the duty of care provided to Mr Fischer.

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

Yours sincerely,

Mr Wild
Advocate of the Deceased
Samuel Jacob Fischer

Dear Robyn Fitzgerald [CCDHB],

Further to this request for release of 'Client pathway policy and procedure for Te Whare o Mataarangi'

Please forward an acknowledgement of correspondence received today 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.

Ms Reuvecamp concluded in her 3.09.19 email that "We understand that the above addresses the further responses from you relating to Mr Fairley’s response of 29 August 2019. Please let us know if we have missed anything".

Please notify Ms Reuvecamp her 3.09.19 has indeed missed a response to this OIA request by not acknowledging or responding to my previous 30.08.19 email, which provided a response to a question asked by Mr Fairley specific to this OIA .

As per my previous email which stated as follows:

Mr Fairley had requested I confirm that the "information I require relates only to the requirements which applied at Te Whare o Matairangi for the period 31 January to 17 April 2015"

I can confirm my request is for information that relates to the requirement (i.e. CCDHB hospital wide policy and procedures and any other health standard) which applied to Te Whare o Matairangi for the period 31 January to 17 April 2015.

I will await a response to Point 3 of this OIA request prior to responding to Mr Fairley's contentions as to Points 1 and Points 2 of this request.

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

By way of confirmation I received your 27.09.19 response to this request for information.

You have only responded to point 3 of this request which was as follows:
My 8.08.19 Point 3 request:
Can you please provide any additional CCDHB Client Pathway Procedures. Manual or policy relevant to the requirements for management and collection of health information for:
a) Mr Fischer's electronic health record (for which I am awaiting release)
b) Mr Fischer's paper file (which has already been released)

Your 27.09.19 Point 3 response:
On review of our files, it appears we previously provided you with this information on 11 August 2015. We attach a copy of our email, and the attachments, for ease of reference. We also attach a copy of the TWOM operations manual, which we understand has also previously been provided to you.

It is of concern that the documents you attached with your reply did not include either of the two additional and conflicting Client Pathway Procedures documents.

CCDHB released what it claimed was the Client Pathway Procedures document in Aug 2015 pursuant to the Official Information Act. In July 2019 in the Coroners Court, CCDHB released a completely different Client Pathway Procedures document pursuant to the Coroners Court. This third release of the Client Pathway Procedures pursuant to the Official Information Act does not include either of the first two documents and according to the hospital wide policies you released on 27.09.19 the TWOM procedures significantly breach hospital wide policies and procedures around what documentation, forms and sections are required to be in a patients file.

I am still awaiting a clear response to Point 2a & 2b which were as follows:
2) Please confirm which specific sections and documents were a MANDATORY requirement to be included
a) within the TWOM paper file
b) within the TWOM electronic health record

Pursuant to the Official Information Act 1982 and the Coroners Act 2006 I request the following information:
1) Confirmation (yes or no) whether the CCDHB procedures document 'Layout for Primary Mental Health Files' which was released pursuant to the Official Information Act on 9.01.15 by the Te Korowai Whariki Operations Manager at the behest of the CCDHB Quality and Assurance Manager a rogue document that breached the official policy and procedures that were in place at the time of its release?

2) Confirmation (yes or no) whether the CCDHB procedures document 'IAU Clinical File Guide' that was presented (as the official procedures document in contrast to that referenced in one above), by a Senior Executive Manager during cross examination in the Coroners Court a rogue document that breached official policy and procedures?

3) Confirmation, (yes or no) whether between 31.01.15 and 17.04.15, CCDHB was in breach of obligations detailed in hospital wide policy and procedures that required patients electronic health information to be collected and secured as an electronic health file that was pursuant to the relevant legislation protecting the rights of access to it by the patient?

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for your 1.11.19 reply which for the purpose of transparency I have copied and pasted below.

This request will be now closed as you have inadvertently provided me with documentation attached to another OIA (despite your declining the document as part of this request).

The document 'Controlled Document and Development Review Policy' provides what I was requesting

Yours sincerely,

Mr Wild

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CCDHB's response:
We believe that we have responded to the matters you raised in your email in our response dated 29 August 2019 to OIA request (our reference) 2019/152.

In that letter, we stated:

"By email dated 8 August 2019, you submitted an OIA request in which you requested confirmation as to the correct Client Pathway document for Te Whore o Matarangi's paper filing system that was in operation between 31 January 2015 and April 2015; confirmation of the specific sections and document which were a mandatory requirement to be included in the paper file and the electronic health record; and any additional CCDHB Client Pathway Procedures, Manual or policy relevant to the requirements for management and collection of health information in relation to Mr Fischer's electronic health record and paper file.

(Name redacted) has given evidence at the Coronial Inquest regarding this matter (see pp186-188 and 221 of the transcript and exhibit 31), which we believe addresses the first two parts of your query."

We understand that this matter was canvassed at the inquest, and that you had the opportunity to cross­ examine (Name redacted) regarding this matter.

We also note that as previously advised in relation to other OIA requests, the DHB is not obliged to form an opinion or create information to answer a request under the OIA.

For the reasons outlined above, we will not be responding further to the matters again raised in your email 7 October 2019 (ref : 2019/10 4a & 152).

You have a right to complain to the Office of the Ombudsman with respect to any refusal of your requests.

Further informat ion about making such a complaint can be found at
htt p:/ / www.ombudsman.parliament.nz/ make-a-comp... complaining-about-access-t o-off icial­ information-551307291224432.

Regards,
Nigel Fairley