This site has not been optimised for Internet Explorer due to Microsoft no longer providing support for the browser. Please view this site using another browser such as Google Chrome or Microsoft Edge.
Te Pū rauemi KOWHEORI-19 COVID-19 resource hub

Support for people working in health during the COVID-19 pandemic. Find information about how you can support yourselves and others, including consumers, teams and colleagues which complements and aligns with Ministry of Health resources.

Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Back to previous page

Project to improve safety in response to mental health and addiction adverse events

Mental health & addiction quality improvement
02 October 2019

The current ways in which mental health and addiction services conduct adverse event reviews and associated processes do not appear to be improving care, and in some cases may contribute to further harm. Reviews are of variable quality and processes can be lengthy and traumatic for those involved.[1, 2, 3]

Consumer and family and whānau groups have also voiced these concerns, along with a need for greater transparency, openness and engagement.[4, 5, 6]

Workshop participants engaged in a co-design practical exercise. From left to right: Fran Voykovich, Hineroa Hakiaha, Sue Cotton and Dr David Hughes, Counties Manukau Health, and Gemma Whittam, Waitematā District Health Board.

The Health Quality & Safety Commission’s mental health and addiction (MHA) quality improvement programme recently launched the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project. The main aims of this project are to engage all stakeholders and improve the experience of consumers, family and whānau and staff involved in an adverse event, as well as supporting district health boards (DHBs) to define a consistent approach to responding to events which result in harm or have the potential to.

Supra-regional co-design workshops were held on 12 September in Auckland and 13 September in Wellington. Around 100 people attended the workshops over the two days including representatives from all 20 district health boards (DHBs), as well as non-governmental organisations (NGOs), partner organisations and Commission staff.

The workshops were an opportunity for participating project teams to:

  • establish who will be part of their project team, including consumer, family, whānau and Māori representatives
  • recognise the value of gathering and using consumer, family and whānau experiences to co-design health care services
  • learn about a range of co-design tools and methods and how to apply them
  • plan for next steps.

Dr Hiran Thabrew, Child Psychiatrist and Paediatrician, Starship Children’s Hospital and Deputy Director Werry Centre for Infant, Child and Adolescent Mental Health, University of Auckland presenting tools and methods to capture co-design.

We were fortunate to have a range of guest speakers at the workshops which was appreciated by the participants who said it was “excellent to have different perspectives.”

  • Cassandra Laskey, Professional Leader Peer Support, Mental Health Service at Counties Manukau Health shared the consumer, family and whānau experience of being part of an adverse events process.
  • David Price, Director of Patient Experience at Waitematā DHB provided a co-design case study.
  • Dr Hiran Thabrew, Child Psychiatrist and Paediatrician at Starship Children’s Hospital and Deputy Director Werry Centre for Infant, Child and Adolescent Mental Health, University of Auckland presented tools and methods for capturing experiences with a tea room design exercise for participants.
  • Helen Harrison, Associate Charge Nurse Manger, and Rose Culy, Senior Physiotherapist, Ward 6 Rehabilitation Ward, Kenepuru Community Hospital shared their co-design case study on patient scheduling.
  • Deon York, Programme Manager, Partners in Care at the Commission, presented on how to capture experiences.

The participating project teams will next meet to share their progress on what they have learnt during their engage, capture and understand phases of the co-design process at the second supra-regional co-design workshop on 11 December in Auckland and 12 December in Wellington. In the meantime, monthly coaching sessions will support the teams on topics such as co-design methodology and case studies.


  1. MHA quality improvement programme quality improvement network and MHA quality improvement programme leadership group.
  2. Oakley Browne MA, Wells JE, Scott KM (eds). 2006. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health.
  3. Government Inquiry into Mental Health and Addiction. 2018. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction,
  4. MHA sector engagement, national and regional meetings. 2017.
  5. Health Quality & Safety Commission. 2018. Learning from adverse events: Adverse events reported to the Health Quality & Safety Commission 1 July 2017 to 30 June 2018. Wellington: Health Quality & Safety Commission.
  6. Moore J, Mello MM. 2017. Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand. BMJ Quality & Safety 0: 1–11.

Relevant pages