Health New Zealand releases inquiry findings

Health New Zealand has released a Summary Report following a review into the incident at Waikato Hospital last month and acknowledges significant failings.

The Rapid Incident Review confirms several failings contributed to the distress and trauma experienced by this young person and their family. Once again, and on behalf of Health NZ, I offer our deepest apologies.

Our staff endeavour to provide high standards of care and we want to ensure what happened in this particular case cannot happen again.

We recognise this young person and their family’s distress. We are continuing to provide appropriate and on-going support.

We accept all of the review the findings. The review team included several senior clinicians from Health NZ, as well as a panel of external experts to Health NZ, who were extensively involved in reviewing and providing feedback.

We will have an action plan in place in the next week to implement the recommendations. These include:

• Apologise to Patient A and her family. Engage with Patient A’s family and provide appropriate support to understand the findings and recommendations, ask any questions, and provide any further feedback into the Waikato Hospital’s adverse event process.

• Undertake a rapid review of international best practice for the identification of unidentified patients, particularly for people with any type of communication difficulty, and create a national policy. This should be done in collaboration with cultural and disability services, and in consultation with the Police.

• Ensure all Emergency Departments undertake medical reviews on unidentified patients.

• Establish a national restraint group to specifically develop best practice for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training. The scope of this group’s work should include developing a checklist for assessment prior to medication restraint, and procedures for monitoring vital signs following sedation in mental health facilities.

• Review admission criteria and procedures for admission to psychiatric intensive care units.

• Review workforce resourcing in the Waikato District’s mental health inpatient unit.

• Ensure cultural support is offered to mental health patients as early as possible in the admission process.

• Engage cultural and disability services in the actioning of relevant recommendations.

We also want to make sure Patient A and their family are given appropriate time and support to understand the findings and recommendations, ask questions, and feedback any concerns into the Waikato Serious Adverse Event report process.

This is an additional review, which is standard process. We review every serious adverse event that occurs in any of our hospitals.

We are continuing to work closely with our staff in the Waikato.