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Report focuses on serious adverse events involving patients of mental health and addictions services

District health boards (DHBs) have reported 177 serious adverse events involving patients of mental health and addictions services in the year to 30 June 2013.

Most events – 87 percent – took place in the community. There were a total of 134 suspected suicides, of which two occurred in inpatient facilities. In 2011/2012, nine suspected suicides occurred in inpatient facilities.

Ninety-two percent of mental health and addictions service users access only community services, with the remaining 8 percent receiving a mixture of community and inpatient services.

The report’s release comes as health quality and improvement experts and health professionals focus on patient safety, at the Asia Pacific (APAC) Forum in Auckland.

APAC is hosted by Ko Awatea and the Institute of Healthcare Improvement and supported by the Commission.

The adverse events are summarised in the report District health board mental health and addictions services: Serious adverse events reported to the Health Quality & Safety Commission 1 July 2012 to 30 June 2013 released today.

The report is available on the Commission’s website: www.hqsc.govt.nz.

It is the Commission’s first report to look specifically at mental health reportable events. Events that occurred at inpatient facilities, while the person was on leave from an inpatient facility and when a person went missing from an inpatient facility were previously included in the annual reporting of serious and sentinel events.

Events that occurred in the community while the person was an outpatient were not reported by the Commission last year.

“This report is the Commission’s first step towards engaging with the challenging problem of harm to patients of mental health and addictions services,” says Dr Janice Wilson, Chief Executive of the Commission.

She says DHB reporting is voluntary but the Commission strongly encourages it so the sector can learn from these very sad events.

Dr Rees Tapsell, Director of Clinical Services, Waikato DHB and Executive Clinical Director at the Midland Regional Forensic Psychiatric Service, says the report contains valuable information for clinicians.

“We have a highly professional and dedicated health workforce but harm does occur.

Not all of it can be prevented but some of it can be. It’s the responsibility of all of us working in health to provide the safest care possible.”

Death by suspected suicide was the most frequently reported event. The way suspected suicides are reported has changed from last year, which required the event to have occurred within seven days of a person’s contact with a mental health and addictions service.

This has been extended to within 28 days of contact with a service, and as a result more cases of death by suspected suicide are likely to be reported in coming years.

The Commission and Ministry of Health have agreed in principle to a two-year mortality review trial to improve knowledge about the factors contributing to suicide, patterns of suicidal behaviour, and for better identification of key points to intervene to prevent suicide.

A small group of experts from different sectors will review the contributing factors and possible intervention points leading to a suicide, with the aim of preventing them in future. A report of their findings and recommendations will be published at the end of the trial.


For more information visit www.hqsc.govt.nz or contact Liz Price at the Health Quality & Safety Commission on 027 695 7744.

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