Mō mātou
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 Aotearoa, 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 Tilah is the Commission’s senior manager, system safety and capability. 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 Carl Horsley is the clinical lead for system safety at the Commission. He is a dual-trained intensivist currently working in Middlemore Hospital, Auckland. He has a research interest in the use of simulation to build system resilience, the sociology of safety and the intersection of te ao Māori and modern safety science.
Carl recently completed his MSc in Human Factors and System Safety at Lund University, Sweden, with a thesis examining the way in which the current safety norm has been formed and stabilised. He is also an active member of the Resilient Healthcare Network, a collaboration of safety scientists, researchers and clinicians exploring the implications of resilience engineering in health care. Carl is particularly interested in how to embed these ideas in everyday practice and has authored several book chapters on aspects of this work.
Dr David Hughes has been working as the clinical lead of the adverse event learning programme at the Commission since 2018. He is also the chief medical officer at PHARMAC. Over the last 10years, he has held several senior clinical leadership roles within the public hospital system in Aotearoa. Originally working in mental health, he became increasingly drawn to addressing system quality and safety issues. He was elected as a fellow of the Royal Australasian College of Medical Administrators in early 2018, having completed a Master of Management degree at Massey University.
Dr Leona Dann is the Commission’s specialist, system safety. Leona is a registered nurse and midwife with a Master of Midwifery and a doctorate in health science. 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.
Glen Mitchell (he/him) is the Commission’s specialist, adverse events, working in the system safety team. Glen is a registered paramedic and prior to joining the Commission worked in the ambulance sector in several roles, including as an intensive care paramedic, clinical educator and clinical safety manager. As clinical safety manager he was responsible for his organisation’s adverse events programme, medication safety and was a member of the National Clinical Guidelines Working Group. Glen is passionate about working with people to change how they think about adverse events, in order to integrate adverse events into wider system quality improvement work.
Sarah Young is the Commission’s advisor, medication safety, working in the system safety team. Sarah is a registered pharmacist with a background in hospital pharmacy. She is passionate about quality use of medicines, quality improvement and consumer advocacy. With 15 years' experience in the health sector, she has worked as project manager, primary care at the Commission, overseeing the Whakakotahi quality improvement programme, and prior to that was programme manager for the safety in practice quality improvement programme for Auckland and Waitematā DHBs. Sarah has completed the DHB quality and performance improvement green belt Lean Six Sigma training.
Gillian Allen is the system safety advisor in the system safety team. She supports mahi relating to adverse events and system safety. She is a registered nurse with a special interest in human factors, having completed a Master of Nursing where her thesis focused on in-situ high-fidelity simulation. Gillian recently worked at a DHB as an associate director of nursing for healthy women, children and youth and has several years’ experience as a clinical educator. Her health career background includes a variety of clinical roles in child health, neonates and the emergency department.
Corry Joseph is a project manager working across the quality systems group. He has worked in a range of public sector organisations in programme and project coordination with a focus on health, education and learning, including the Ministry of Education, University of Otago and Victoria University of Wellington. Corry holds a Bachelor of Arts from the University of Otago. He is currently providing parental leave cover for Kat Lawrie.
Matt Coulson is a coordinator for the quality systems group. His responsibilities include the organisation of meetings and events, generating minutes, logistics, payments and other administrative support. He holds a degree in urban studies and public health and has previously worked in adult secondary education and in military intelligence.
Caroline Tilah
Caroline Tilah is the Commission’s senior manager, system safety and capability. 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 Carl Horsley
Dr Carl Horsley is the clinical lead for system safety at the Commission. He is a dual-trained intensivist currently working in Middlemore Hospital, Auckland. He has a research interest in the use of simulation to build system resilience, the sociology of safety and the intersection of te ao Māori and modern safety science.
Carl recently completed his MSc in Human Factors and System Safety at Lund University, Sweden, with a thesis examining the way in which the current safety norm has been formed and stabilised. He is also an active member of the Resilient Healthcare Network, a collaboration of safety scientists, researchers and clinicians exploring the implications of resilience engineering in health care. Carl is particularly interested in how to embed these ideas in everyday practice and has authored several book chapters on aspects of this work.
Dr David Hughes
Dr David Hughes has been working as the clinical lead of the adverse event learning programme at the Commission since 2018. He is also the chief medical officer at PHARMAC. Over the last 10years, he has held several senior clinical leadership roles within the public hospital system in Aotearoa. Originally working in mental health, he became increasingly drawn to addressing system quality and safety issues. He was elected as a fellow of the Royal Australasian College of Medical Administrators in early 2018, having completed a Master of Management degree at Massey University.
Dr Leona Dann
Dr Leona Dann is the Commission’s specialist, system safety. Leona is a registered nurse and midwife with a Master of Midwifery and a doctorate in health science. 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.
Glen Mitchell
Glen Mitchell (he/him) is the Commission’s specialist, adverse events, working in the system safety team. Glen is a registered paramedic and prior to joining the Commission worked in the ambulance sector in several roles, including as an intensive care paramedic, clinical educator and clinical safety manager. As clinical safety manager he was responsible for his organisation’s adverse events programme, medication safety and was a member of the National Clinical Guidelines Working Group. Glen is passionate about working with people to change how they think about adverse events, in order to integrate adverse events into wider system quality improvement work.
Sarah Young
Sarah Young is the Commission’s advisor, medication safety, working in the system safety team. Sarah is a registered pharmacist with a background in hospital pharmacy. She is passionate about quality use of medicines, quality improvement and consumer advocacy. With 15 years' experience in the health sector, she has worked as project manager, primary care at the Commission, overseeing the Whakakotahi quality improvement programme, and prior to that was programme manager for the safety in practice quality improvement programme for Auckland and Waitematā DHBs. Sarah has completed the DHB quality and performance improvement green belt Lean Six Sigma training.
Gillian Allen
Gillian Allen is the system safety advisor in the system safety team. She supports mahi relating to adverse events and system safety. She is a registered nurse with a special interest in human factors, having completed a Master of Nursing where her thesis focused on in-situ high-fidelity simulation. Gillian recently worked at a DHB as an associate director of nursing for healthy women, children and youth and has several years’ experience as a clinical educator. Her health career background includes a variety of clinical roles in child health, neonates and the emergency department.
Corry Joseph
Corry Joseph is a project manager working across the quality systems group. He has worked in a range of public sector organisations in programme and project coordination with a focus on health, education and learning, including the Ministry of Education, University of Otago and Victoria University of Wellington. Corry holds a Bachelor of Arts from the University of Otago. He is currently providing parental leave cover for Kat Lawrie.
Matt Coulson
Matt Coulson is a coordinator for the quality systems group. His responsibilities include the organisation of meetings and events, generating minutes, logistics, payments and other administrative support. He holds a degree in urban studies and public health and has previously worked in adult secondary education and in military intelligence.
Last updated: 8th March, 2022
