Hutt Valley District Health Board has apologised to the family of an intellectually impaired woman, who died after being released from hospital, because staff had failed to recognise she may have also been mentally ill .
The apology came after a Health and Disability Commissioner investigation into the woman's death in 2010. The commissioner's report was released on Tuesday.
The woman, who is not named, suffered brain damage from a brain aneurysm shortly after birth.
Between 2007 and the time of her death she was often in Hutt Hospital emergency department for self harm or police had picked her up wandering at night.
She had frequently contacted emergency services declaring that she intended to kill herself because she did not want to keep living with her parents.
A number of times the health board's Crisis Assessment and Treatment Team (CATT) assessed her as not having a mental illness. Her behaviour was attributed to her intellectual impairment.
After her (CATT) final visit she was returned home, but she ran away and her body was found a short time later.
According to the commissioner's report, it was not until she made an ACC claim and was seen by a psychologist that she was identified as having several "Axis 1" clinical disorders.
A psychiatrist did not believe the underlying cause of her erratic behaviour was her intellectual disability.
However, their reports were not provided to health board.
The commissioner said a number of agencies were involved in the woman's care, but no one agency took the lead role.
The health board acknowledged it failed to identify a lead provider, among other failures. It acknowledged "diagnostic overshadowing" - where symptoms of illness are incorrectly attributed to a person's intellectual disability - was possible in the woman's case.
The mental health service's differing levels of expertise resulted in it failing to adequately assess and refer her.
It had made changes to ensure it did not repeat the mistake.
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