Our mahi reflects the Commission’s role as an agent of influence for system learning and change. Also, this work must acknowledge the specific context of health care in New Zealand, incorporating te ao Māori and building on the World Health Organization’s global patient safety action plan.
Meet the systems safety team
Together we support the health sector and provide expert system safety advice by drawing on the team’s collective knowledge, current evidence and experience in safety and quality.
Caroline is the Senior Manager, System Safety. Before this she was the executive director operations for the quality improvement and patient safety directorate at Capital & Coast District Health Board (DHB). Caroline is a registered nurse with a postgraduate qualification in occupational health and has completed the Institute for Healthcare Improvement’s quality improvement advisor training. She has held several quality and clinical roles, and her passion is working in partnership to improve care.
Leona is the Specialist, System Safety. Leona is a registered nurse and a midwife with a Master of Midwifery, a doctorate in health science and a postgraduate certificate in ergonomics/human factors. She was a lead maternity care midwife and has also worked in various midwifery leadership positions in DHBs and nationally. Her areas of interest include human factors, learning through understanding the lived experience, the overlap between systems thinking and mātauranga Māori, and restorative responses to health care harm.
Rebekah is an advisor in the System Safety team supporting the mahi relating to harm events and system safety. Initially working in the medico-legal space, she then re-trained as a registered nurse and has worked primarily in Emergency and Critical Care. Alongside her clinical practice, she has also held research and quality improvement roles before becoming a Quality and Risk Manager for Acute and Critical Care Services. Rebekah’s areas of interest include harm events and how we respond to these with a restorative practice approach, and she is particularly interested in growing a community of practice around the learning review methodology.
Karen Gibson is the System Safety Strategy and the National Quality Forum Project Manager. With an MBA specialising in project management, she brings experience across diverse project environments, spanning government, humanitarian emergency relief and development, and the telecommunications industry. Most recently, she was a project and quality advisor at a Primary Health Organisation.
Rachel is a System Safety Advisor. A registered nurse with more than 30 years' experience across the New Zealand health sector, she holds a Master of Health Sciences with First Class Honours from the University of Auckland. Rachel worked in Clinical Nurse Specialist roles, including oncology, pain management and pre-assessment services, before moving into quality and risk management and later quality improvement roles within district health services. Before joining the System Safety team, she was part of the Quality Improvement team. Rachel's areas of interest include systems thinking, learning from harm events, restorative approaches to harm, and strengthening safety and quality across the health system.
Carol is the Programme Coordinator and has worked within the health sector for several years. She is also experienced in event management and completed the Prince2 Project Management Foundation course. She supports the planning, coordination, and delivery of the system safety programme and initiatives, supporting the team to be aligned, organised, and focused on achieving outcomes. Carol is passionate about fostering collaboration, building effective working relationships, and contributing to projects that create positive impact. She brings a strong commitment to coordination, communication, and continuous improvement, ensuring programme activities are delivered efficiently and successfully.
Caroline Tilah
Caroline is the Senior Manager, System Safety. Before this she was the executive director operations for the quality improvement and patient safety directorate at Capital & Coast District Health Board (DHB). Caroline is a registered nurse with a postgraduate qualification in occupational health and has completed the Institute for Healthcare Improvement’s quality improvement advisor training. She has held several quality and clinical roles, and her passion is working in partnership to improve care.
Dr Leona Dann
Leona is the Specialist, System Safety. Leona is a registered nurse and a midwife with a Master of Midwifery, a doctorate in health science and a postgraduate certificate in ergonomics/human factors. She was a lead maternity care midwife and has also worked in various midwifery leadership positions in DHBs and nationally. Her areas of interest include human factors, learning through understanding the lived experience, the overlap between systems thinking and mātauranga Māori, and restorative responses to health care harm.
Rebekah Mitchell
Rebekah is an advisor in the System Safety team supporting the mahi relating to harm events and system safety. Initially working in the medico-legal space, she then re-trained as a registered nurse and has worked primarily in Emergency and Critical Care. Alongside her clinical practice, she has also held research and quality improvement roles before becoming a Quality and Risk Manager for Acute and Critical Care Services. Rebekah’s areas of interest include harm events and how we respond to these with a restorative practice approach, and she is particularly interested in growing a community of practice around the learning review methodology.
Karen Gibson
Karen Gibson is the System Safety Strategy and the National Quality Forum Project Manager. With an MBA specialising in project management, she brings experience across diverse project environments, spanning government, humanitarian emergency relief and development, and the telecommunications industry. Most recently, she was a project and quality advisor at a Primary Health Organisation.
Rachel Pola
Rachel is a System Safety Advisor. A registered nurse with more than 30 years' experience across the New Zealand health sector, she holds a Master of Health Sciences with First Class Honours from the University of Auckland. Rachel worked in Clinical Nurse Specialist roles, including oncology, pain management and pre-assessment services, before moving into quality and risk management and later quality improvement roles within district health services. Before joining the System Safety team, she was part of the Quality Improvement team. Rachel's areas of interest include systems thinking, learning from harm events, restorative approaches to harm, and strengthening safety and quality across the health system.
Carol Harley
Carol is the Programme Coordinator and has worked within the health sector for several years. She is also experienced in event management and completed the Prince2 Project Management Foundation course. She supports the planning, coordination, and delivery of the system safety programme and initiatives, supporting the team to be aligned, organised, and focused on achieving outcomes. Carol is passionate about fostering collaboration, building effective working relationships, and contributing to projects that create positive impact. She brings a strong commitment to coordination, communication, and continuous improvement, ensuring programme activities are delivered efficiently and successfully.
Published: 8 Mar 2022
Modified: 22 Sep 2025
