Health authorities refuse to reveal serious and fatal mistakes

Monday, 2 December 2024

Way back in 2007, then Chief Ombudsman Dame Beverley Wakem ruled Wellington's health board had to release details of serious mishaps.

Health authorities refuse to reveal details of the most serious and fatal mistakes in the health system, despite a previous Ombudsman’s ruling that the information must be released.

From 2008, health authorities published summaries of preventable serious and sentinel events by region. That includes the most major and fatal incidents, such as the unexpected deaths of babies and suspected suicides in hospital mental health wards.

The report resulted from a 2007 ruling by then Chief Ombudsman Dame Beverley Wakem (following a complaint from The Post) that the information was in the public interest.

“Serious and sentinel events are a class of incidents in the public health system where something has gone seriously wrong. When one of these incidents happens, there is a public interest in knowing, in general terms at least, what went wrong and what measures will be taken to prevent it happening again,' Wakem wrote.

But the summaries were quietly discontinued, as part of a revamp of the national policy for reporting on adverse events. They were replaced by quarterly data dashboards, which list only the broad category of problem such as medication error, fall.

Introducing the 2008/09 national serious and sentinel events report, chairman of the quality improvement committee, Pat Snedden, supported publicly reporting medical mishaps.

So in May 2024, The Post again requested summaries of all the serious and sentinel events in the health system during 2023, and provided a link to Wakem’s decision.

Health NZ took two months to respond, but in July said it was preparing the data. Four months later - six months after the original request - it refused to provide the summaries.

Health NZ OIA manager Danielle Coe said the agency started the process in good faith but realised part-way through that summaries were no longer routinely written.

“In addition to having no mandate to produce summaries of adverse events for public release, they are not something Health NZ has the dedicated organisational capacity to produce,” Coe said.

Health NZ did release summaries of maternity incidents that it compiled for another OIA request, reinforcing the ongoing demand for the information.

Coe said Health NZ would consider a narrower request. However, the request was already limited to only the events causing serious harm or death.

The adverse event reporting system is run by the Health Quality and Safety Commission. Commission clinical director Martin Thomas said switching to quarterly reporting allowed them to more quickly identify potential problem areas.

Thomas said the commission stopped publishing summaries of serious incidents, because the new reporting policy focused on “healing, learning and improving from harm”, and publishing details of individual incidents could discourage people from reporting when things went wrong.

However, The Post was told back in 2007 that publishing the adverse event summaries would make health workers too scared to report incidents and make the public too scared to go to hospital. Neither happened.

While it no longer produces adverse event summaries, Health NZ still provides anonymised versions of the full reports to HQSC. When The Post asked for those reports, it was told it must specify a region before the request would even be considered.

The Post has complained to the Ombudsman, again.