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21 November, 2012

Message from CDHB Chief Executive Officer Mary Bonner

We welcome today’s publication by the Health, Quality & Safety Commission (HQSC) about Serious and Sentinel (SAC 1 & 2) Events across New Zealand’s District Health Boards (DHBs) for the 2011/12 year. Every one of these events is one too many and I am sorry that they have occurred. We always seek to learn from these incidents and improve safety. We can’t do this if we don’t know about incidents and I want to acknowledge the strong safety culture we have at CCDHB of reporting incidents. I want to thank our staff, patients and their families, other health providers - in particular our general practitioners and primary health nurses - for telling us when an incident has occurred and raising concerns so that we can review what happened.

Strengthening our culture of patient safety and quality continues to be a priority. We are committed to working with patients and families when things go wrong to ensure that their concerns and needs are addressed and supported, and that they are included in the process of the review.

Our practice is to communicate openly with patients and families when adverse events occur, to acknowledge what has happened openly and to apologise where we have got things wrong. We listen to their concerns, provide support, involve them to the degree they prefer, and where possible answer their questions and address any concerns that they have.

This year HQSC has asked each DHB to report its own events. CCDHB has posted a summary report today and you can read it here. CCDHB is reporting 19 incidents that occurred across a number of services.

The serious and sentinel events published today relate to patient harm or death and I unreservedly apologise to the patients and families involved. We fully accept our responsibility for providing safe health care and are strongly committed to patient safety. CCDHB routinely shares what we learn from reviewing adverse events with other health providers and in turn, we seek to learn from others. We have a dedicated Patient Safety Officer and Quality Managers and Facilitators who work alongside staff, patients and families to improve patient safety and healthcare delivery.

We encourage our staff, and patients and families, primary health and community providers to tell us when things go wrong, or if they notice a problem, as this is the first step in learning and creating a strong culture of patient safety. If there are things we can do better, or if we get it wrong, we need to know. By reviewing and evaluating our systems we can learn and change and improve the quality of all our patient’s experiences.

We are very concerned to have had three inpatient deaths by suicide during this period. CCDHB has not had an inpatient death by suicide incident since 2004. These incidents are very worrying, devastating for the families and the staff and services involved. I can assure you we take such incidents very seriously. Each case has been, or is currently being, reviewed. We are in communication with each family to the degree they prefer to be involved. Each event occurred in quite different circumstances. Where the need for change has been identified, this has been implemented. We have made our observations policy clearer and audited staff practice in relation to observations confirming that practice has changed. We acknowledge that this client group are at high risk of suicide and that this should not be able to occur in inpatient units. In addition to the review of each incident, CCDHB has commissioned an independent review of inpatient suicide incidents, which is currently in progress. We have taken this step of getting an independent look at our own reviews to be certain we have missed nothing in our efforts to improve safety and reduce risk in our Mental Health services.

We are also very concerned about the six patients whose diagnosis and treatment was delayed because of issues with referrals or a failure to follow-up test investigation results. We have been in communication with each patient and/or family to the degree they prefer to be involved. We have carefully reviewed each of the incidents and we have already made a number of service specific changes to processes as a result of each review.

We are working hard to ensure that services, teams and clinics are reviewing their processes to make sure patient results are reviewed and responded to. We have also recorded a formal risk on the DHB’s risk register and will be auditing the above changes to be certain we have made enough changes to avoid such incidents. In early 2013 we are bringing in an electronic review and sign-off of results system. This new system will provide a more robust way of alerting staff if the correct follow-up procedures have not occurred and will reduce the risk of such incidents occurring.

It is important to note that serious adverse events are rare. To put these numbers in context each year in our district we undertake more than 425,000 patient appointments, procedures and operations – including more than 115,000 radiology procedures– almost all without adverse incident.

To have even one event is not good enough and like every DHB we aim for zero patient harm. I commend HQSC for their work in publishing the national report and for considering how together, the sector and health care users can improve safety.

Mary Bonner