South third highest patient events in NZ

21:18, Sep 26 2013

The Southern District Health Board has reported 21 "serious adverse events" by people accessing mental health and addiction services - the third highest number nationally.

Serious and adverse events can include suicides, attempted suicides and other serious events involving both mental health in-patients and outpatients.

It was the first time the information had been reported by the Health Quality and Safety Commission, and it comes after policy changes to the hospital reporting in 2011-12.

The incidents had previously been included in the commission's serious and sentinel event report, but were separated out for the first time this year.

Commission chief executive Dr Janice Wilson said the report, for the year to June, was its first step toward "engaging with the challenging problem of harm to patients of mental health and addictions services".

The DHB reporting was voluntary but the commission encouraged it so the sector could learn from the "very sad events".


The report revealed there were 177 cases of serious adverse events nationwide, with one of those being a Wellington mental health patient who slipped his minders and stabbed a stranger several times.

Of the 177 cases, 136 happened while clients were classified as outpatients and five while they were on leave from a facility.

A further 12 happened when mental health patients went missing from an in-patient unit, and 24 more happened within a mental health facility.

Suicide was the most common serious incident reported, with 134 mental health patients taking their own lives between July 2012 and June this year. Of those, 122 were outpatients.

There were 17 cases of serious self harm. Another 17 incidents were described as "serious adverse behaviour," and involved allegations of patients assaulting staff or other patients, or committing criminal acts.

There were five incidents of patients going missing from an in-patient facility - with no harm caused - and four "other events," resulting in harm to patients.

The board which reported the highest number of serious adverse events was Waitemata, with 27, followed by Canterbury, with 24.

Auckland reported 17 serious adverse events, four fewer than the Southern District Health Board.

The Southern District Health Board was unable to respond before deadline.

The Southland Times