21 serious adverse events

Mental health and addiction services in the South had 21 serious adverse events last year, a new report shows.

The Health Quality and Safety Commission report is the first to compile the incidence of serious adverse events in mental health and addiction services, in both inpatient and outpatient services.

Of the 177 serious adverse events nationally in 2012-13, 134 were suicide.

The other events were: serious self-harm (17), serious adverse behaviour (17), going missing from a facility (causing no harm, 5), other event resulting in patient harm (4).

Most of the events, 87%, involved patients in the community, where 90% of care is provided.

Its 21 incidents put the Southern District Health Board third of the 20 health boards. However, incidents are not shown by type for each board.

Commission chief executive Dr Janice Wilson said the report was a first step in tackling the problem of harm to mental health and addiction service patients.

The commission and the Ministry of Health had agreed previously to conduct a two-year mortality review trial related to patterns of suicidal behaviour, and to find ways to identify intervention points for suicide prevention.

A report of the expert group's findings and recommendations would be published at the end of the trial.

It was not possible to compare suicide numbers with suicides reported in previous years, because they now counted patients who had had contact with mental health services within 28 days, rather than the previous measure of seven days.


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