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Principles for engaging consumers and whānau in mental health and addiction adverse event reviews

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This information is provided for mental health and addiction (MHA) services. It is intended to guide adverse event[1] review facilitators on the principles of engaging with consumers and their whānau[2] affected by an adverse event and to complement the Health Quality & Safety Commission resources Engaging with consumers following an adverse event and Guide to partnering with whānau following an adverse event.

Cultural needs

  • Ensure psychological safety[3] for all involved in the adverse event review process.
  • Seek cultural advice and support throughout the review process.
  • Be led by the principles of whakawhanaungatanga[4] and kotahitanga.[5]
  • Ensure everyone understands the purpose of each part of the process.
  • Be clear about the parameters and limitations of the process.
  • Clarify the expectations of those involved in the process.
  • Follow tikanga[6] practices.
  • Have processes in place to support staff resilience so staff can respond when and where needed after an adverse event.
  • Encourage staff to demonstrate flexibility and adaptability when working with consumers and whānau, both during and after a serious event review.
  • Be compassionate – listen to understand.


  • Keep stories of the consumer experience at the heart of your work.
  • Provide training in the adverse event review process to your consumer leaders, consumer advisors and whānau advisors.
  • Understand and work to address the power dynamics that exist in health systems and between consumer and clinical roles.
  • When involving consumers (both the consumer, staff and/or those affected by the adverse event) be clear what you are asking people to do. Clarify roles, responsibilities and expectations – from both perspectives.
  • Offer coaching and mentoring to consumers involved in the review process/team, especially if they are at the early stage in their experience of adverse event reviews.


  • Timelines for reviews are to be developed in consultation with the affected whānau.
  • Aim to complete everything that happens in partnership with the affected whānau.
  • Appoint a 'connector' from your team, who stays involved and provides ongoing information on the process (eg, whānau liaison).
  • Ask whānau if they want to nominate a spokesperson to stay connected, if the whānau themselves are not ready to be involved.
  • Be clear that you are speaking to the nominated spokesperson – as designated by the whānau.
  • Ask whānau what their preferences are for cultural and other support required.
  • Whānau are unique – respect and honour this.
  • Establish a centralised log of all whānau contacts: by who, when, actions and next steps. Summarise outcomes.
  • Meet with whānau at places and times that are convenient and safe for them.


[1] An adverse event is ‘an event with negative or unfavourable reactions or results that are unintended, unexpected or unplanned (also referred to as ‘incident’ or ‘reportable event’). In practice this is most often understood as an event which results in harm or has the potential to result in harm to a consumer’. See page 7 of: Health Quality & Safety Commission. 2017. National Adverse Events Reporting Policy. Wellington: Health Quality & Safety Commission.

[2] ‘Whānau’ means a set of relationships a consumer or proposed consumer recognises as their closest connections, whether those connections are with a collective or an individual. The relationships are not limited to those based on blood ties and may include any of the following: the spouse or partner of the consumer or proposed consumer; relatives of the consumer or proposed consumer; a mixture of relatives, friends and others in a support network; only non-relatives of the consumer or proposed consumer. RANZCP. 2000. Involving Families: Guidance notes: Guidance for involving families and whānau of mental health consumers/tangata whai ora in care, assessment and treatment processes. Wellington: Ministry of Health.

[3] Psychological safety – a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. Edmondson A. 2018. The Fearless Organization: Creating psychological safety in the workplace for learning, innovation, and growth. New Jersey: John Wiley & Sons.

[4] Whakawhanaungatanga – process of establishing relationships, relating well to others (

[5] Kotahitanga – unity, togetherness, solidarity, collective action (

[6] Tikanga – … the customary system of values and practices that have developed over time and are deeply embedded in the social context (