In 2011, the Health Quality & Safety Commission (the Commission) made a decision to separate district health board (DHB) mental health and addictions services serious adverse events (SAEs) from the main SAE report, and to support the sector in its approach to reviewing and reporting SAEs. The following report is the first from the Commission specifically focused on SAEs affecting patients of DHB mental health and addictions services.
The majority of events summarised in this report resulted in serious harm to a patient of a DHB mental health and addictions service. They were subsequently reported to the Commission in accordance with the process for reporting SAEs set out in the Commission’s national reportable events policy.
The number of SAEs reported by each DHB reflects the size of the population served and the services provided by each. However, it should be emphasised that SAE reporting is not intended to be an epidemiologically accurate ‘count’ of events to allow comparisons between hospitals or services.
Reporting of SAEs to the Commission is strongly encouraged but is voluntary. The significance of reporting these events lies in the lessons learnt following local review of the incidents.
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