A high-level review into suicide prevention is likely after
134 suspected suicides were reported last year within 28 days
of patients having contact with mental health and addictions
New Zealand's district health boards (DHBs) have reported 177
serious adverse events involving patients in the last year.
A Health Quality & Safety Commission report, released
today, found 87 percent of adverse events took place in the
There were a total of 134 suspected suicides, with two
occurring in inpatient facilities.
"This report is the commission's first step towards engaging
with the challenging problem of harm to patients of mental
health and addictions services," said Dr Janice Wilson, chief
executive of the commission.
The report's release comes as health quality and improvement
experts and health professionals focus on patient safety at
the Asia Pacific Forum in Auckland this week.
It is the commission's first report to look specifically at
mental health reportable events.
Events that occurred at inpatient facilities, while the
person was on leave from an inpatient facility and when a
person went missing from an inpatient facility were
previously included in the annual reporting of serious and
Events that occurred in the community while the person was an
outpatient were not reported by the commission last year.
While DHB reporting is voluntary, the commission "strongly
encourages it so the sector can learn from these very sad
events", Dr Wilson said.
Ninety-two percent of mental health and addictions service
users access only community services, with the remaining
eight percent receiving a mixture of community and inpatient
Dr Rees Tapsell, director of clinical services at Waikato DHB
and executive clinical director at the Midland Regional
Forensic Psychiatric Service, said the report contains
valuable information for clinicians.
"We have a highly professional and dedicated health workforce
but harm does occur," he said.
"Not all of it can be prevented, but some of it can be.
"It's the responsibility of all of us working in health to
provide the safest care possible."
Death by suspected suicide was the most frequently reported
serious adverse event reported to the Health Quality &
Safety Commission between July 1, 2012 and June 30, this
The way suspected suicides are reported has changed from last
year, which required the event to have occurred within seven
days of a person's contact with a mental health and
It has been extended to within 28 days of contact with a
service. As a result, more cases of death by suspected
suicide are likely to be reported in coming years, the
Now, the commission and Ministry of Health have agreed in
principle to a two-year mortality review trial to improve
knowledge about the factors contributing to suicide, patterns
of suicidal behaviour, and for better identification of key
points to intervene to prevent suicide.
A small group of experts from different sectors will review
the contributing factors and possible intervention points
leading to a suicide, with the aim of preventing them in
A report of their findings and recommendations will be
published at the end of the trial.
- Kurt Bayer of APNZ