New Zealand has an excellent health care system which provides safe and efficient care to the vast majority of people using its services. However, adverse events can still occur due to failures in the system. At the centre of every adverse event there is a consumer and their whānau. We have a responsibility to these people to review, learn, implement effective changes to the system and share learnings across health and disability services.

The Commission’s adverse events learning programme guides and supports New Zealand’s health and disability services with a nationally consistent approach to reporting, review and learning from adverse events and near misses.

Adverse events learning programme team

  • Dr David Hughes, clinical lead
  • Sandy Blake, clinical expert
  • Caroline Tilah, manager, patient safety
  • Glen Mitchell, specialist, adverse events
  • Susan Melvin, advisor, patient safety
  • Jane Lester, programme coordinator
  • Kat Lawrie, programme coordinator (on parental leave until early 2020).

To contact the adverse events learning programme team email

Matthew was 16-years-old when he developed appendicitis. His mum, Heather, took him to the local emergency department where he had surgery that night to remove his appendix. In this video, Heather talks about the events leading up to Matthew's surgery and what happened in the two days afterward.


Last updated 09/01/2019