Charlotte Korte
Tēnā koutou katoa, ko Charlotte Korte tōku ingoa. I am here to present our submission to you along with my colleagues Denise Astill and Sue Claridge.
We are here to urge you to take action to address the preventable medical harm that is happening within our health system.
Consumers, whanau and clinical staff are gravely concerned at:- the preventable medical harm that is occurring, - that this is being exacerbated by increasing issues in our health system, and- the lack of effective responses to address systemic issues.
We cannot afford to let this continue. Our health, and the safety of New Zealanders is too important!
Harm can happen to anyone. Unintended consequences affect all New Zealanders. It isn’t just the first instance of harm, the second, third, or even the near misses.
Despite known issues, our health entities fail to act quickly, often reacting only after serious harm has occurred.
Both consumers and health staff are not being heard. Concerns are dismissed, and action is delayed. We are told repeatedly that preventable medical harm is not a problem, or an issue because "there are no data to suggest this is so." If data is not collected and monitored, how can it show anything?
This claim is absurd given our siloed and ineffective data capture systems.
It should never be left up to harmed consumers to prove that there is a problem. The burden of proof, must be on the system to ensure safety.
The HQSC are developing a formal safety strategy which we fully support- 100%. This will show what should happen, and what is expected as far as health safety standards go.
However, without an independent body to monitor its implementation, it risks becoming another well-intended strategy that looks great on paper, but fails in practice.
This doesn’t just affect health consumers. Who is looking after our health professionals?
We canvassed our health workforce and spoke to many health professionals. They continue to witness avoidable harm, sometimes severe, yet feel powerless to stop it. The secondary harm our health care professionals are experiencing is significant. This needs to be acknowledged, and it must be taken more seriously.
We are aware of a patient deterioration pathway called Korero Mai. Where this has been implemented well, it has the potential to improve patient safety. We have struggled however, to get any information on the extent with which it has been implemented across NZ hospitals. Once again there is currently no data relating to where this has been implemented, how visible it is, and how well it is working. This is a missed opportunity and we urge you to address these issues to ensure that Korero Mai is embedded and highly visible across all hospitals. Yet another example of where our reporting and monitoring systems are failing, relates to the legal requirement of ACC to report severe adverse events to the HQSC- as Severity Assessment Codes SAC 1 and 2 events. An OIA in 2024 revealed that ACC has been only reporting SAC 1 events, not SAC 2. This means severe adverse events are falling through the cracks, and we cannot learn from this data to ensure the system is changed to prevent it from happening again. We urge you to investigate what actions were taken by our Health Entities to address this. Our health system failures have persisted for decades. It’s time to do something different, we need an independent Patient Safety Commissioner that will put health, and patient safety first! An independent Patient Safety Commissioner will rebuild trust and ensure our health system is safer than it is now.
Thank you, I will now handover to Denise.
We are here to urge you to take action to address the preventable medical harm that is happening within our health system.
Consumers, whanau and clinical staff are gravely concerned at:- the preventable medical harm that is occurring, - that this is being exacerbated by increasing issues in our health system, and- the lack of effective responses to address systemic issues.
We cannot afford to let this continue. Our health, and the safety of New Zealanders is too important!
Harm can happen to anyone. Unintended consequences affect all New Zealanders. It isn’t just the first instance of harm, the second, third, or even the near misses.
Despite known issues, our health entities fail to act quickly, often reacting only after serious harm has occurred.
Both consumers and health staff are not being heard. Concerns are dismissed, and action is delayed. We are told repeatedly that preventable medical harm is not a problem, or an issue because "there are no data to suggest this is so." If data is not collected and monitored, how can it show anything?
This claim is absurd given our siloed and ineffective data capture systems.
It should never be left up to harmed consumers to prove that there is a problem. The burden of proof, must be on the system to ensure safety.
The HQSC are developing a formal safety strategy which we fully support- 100%. This will show what should happen, and what is expected as far as health safety standards go.
However, without an independent body to monitor its implementation, it risks becoming another well-intended strategy that looks great on paper, but fails in practice.
This doesn’t just affect health consumers. Who is looking after our health professionals?
We canvassed our health workforce and spoke to many health professionals. They continue to witness avoidable harm, sometimes severe, yet feel powerless to stop it. The secondary harm our health care professionals are experiencing is significant. This needs to be acknowledged, and it must be taken more seriously.
We are aware of a patient deterioration pathway called Korero Mai. Where this has been implemented well, it has the potential to improve patient safety. We have struggled however, to get any information on the extent with which it has been implemented across NZ hospitals. Once again there is currently no data relating to where this has been implemented, how visible it is, and how well it is working. This is a missed opportunity and we urge you to address these issues to ensure that Korero Mai is embedded and highly visible across all hospitals. Yet another example of where our reporting and monitoring systems are failing, relates to the legal requirement of ACC to report severe adverse events to the HQSC- as Severity Assessment Codes SAC 1 and 2 events. An OIA in 2024 revealed that ACC has been only reporting SAC 1 events, not SAC 2. This means severe adverse events are falling through the cracks, and we cannot learn from this data to ensure the system is changed to prevent it from happening again. We urge you to investigate what actions were taken by our Health Entities to address this. Our health system failures have persisted for decades. It’s time to do something different, we need an independent Patient Safety Commissioner that will put health, and patient safety first! An independent Patient Safety Commissioner will rebuild trust and ensure our health system is safer than it is now.
Thank you, I will now handover to Denise.
Denise Astill
Imagine you’re living your best life. You’ve got a great job, about to start your own family, and BANG your whole life as you know it disintegrates. No longer can you have a career, instead your children are going to need you to care for them for the rest of your life, and you must plan for someone to look after them when you’re gone.
I don’t have to imagine it! This is my life, but also the life for a lot of other NZs.
The healthcare system systemically failed me and continues to fail not only myself but thousands of New Zealanders.
My babies were exposed to sodium valproate (known as Epilim here in NZ). The archive documents show that the Government agencies knew that this medication could harm a baby if exposed during pregnancy prior to this medication coming onto the NZ market in 1975, yet to this date there are no legislative safety systems in place around medications in pregnancy. First was thalidomide, next valproate and other anti-seizure medications, but what’s around the corner?
The purple pills that I popped every day during my pregnancy to control my epilepsy has caused catastrophic effects to my daughters, me, my husband, my family and my whānau. I asked the right questions to two specialists, but was ill-advised, not getting informed consent or informed choice, and there were no warnings on the boxes or foil. As a result, the red on this sheet demonstrates the areas just one of my daughters has been affected, and more is being discovered as she ages.
I don’t have to imagine it! This is my life, but also the life for a lot of other NZs.
The healthcare system systemically failed me and continues to fail not only myself but thousands of New Zealanders.
My babies were exposed to sodium valproate (known as Epilim here in NZ). The archive documents show that the Government agencies knew that this medication could harm a baby if exposed during pregnancy prior to this medication coming onto the NZ market in 1975, yet to this date there are no legislative safety systems in place around medications in pregnancy. First was thalidomide, next valproate and other anti-seizure medications, but what’s around the corner?
The purple pills that I popped every day during my pregnancy to control my epilepsy has caused catastrophic effects to my daughters, me, my husband, my family and my whānau. I asked the right questions to two specialists, but was ill-advised, not getting informed consent or informed choice, and there were no warnings on the boxes or foil. As a result, the red on this sheet demonstrates the areas just one of my daughters has been affected, and more is being discovered as she ages.
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The only effective changes that have occurred in the 50 years since valproate came on the NZ market is because of me, the consumer squeaky wheel, setting up a charitable organisation, but why is it up to those that are harmed to advocate passionately for changes. NZ should be leading in patient safety, but unfortunately, we are dragging way behind.
People like us who have been harmed by systemic failures have little trust in the health system, when seeing specialists, therapists, and going to hospital. We feel anxious, unsafe, and vulnerable. This has caused compounded and intergenerational harm.The UK PSC was set up based on the Cumberlege review on primidos, valproate, and mesh. Having an independent PSC here in Aotearoa NZ is necessary and must happen.This is in your hand; this is a positive change.Trust me you DO NOT want to have to go through what our family has. You don’t want to be the one quietly crying in the shower because you are overwhelmed and are feeling the guilt and grief of what could have or should have been.
I'm going to hand over to Sue.
Sue Claridge
An independent Patient Safety Commissioner could make a real difference to our health system and, as it is in England, it should be should be seen in a positive light.
England’s Patient Safety Commissioner, Dr Henrietta Hughes, told us when we met with her that all parts of the health system want to be at the table with her, working for a safer health system. She works collaboratively with the whole sector; drives systemic change, helps to improve the safety culture, reduce preventable harm, promote transparency and break down the barriers that exist between the health entities so they can work more effectively together. Our NZ health entities face similar barriers!
Proactive early intervention and harm prevention costs less than retrospectively treating the impact of harm. The incredible financial and human burden of harm in our health system cannot be overstated.
An independent Patient Safety Commissioner will reduce downstream health costs and ACC costs, and enable New Zealanders to live healthier more productive lives, the lives that they deserve.
New Zealanders are crying out for systemic change. We have the opportunity to be among world leaders in patient safety through the establishment of an independent Patient Safety Commissioner. This would be a be a lasting legacy for New Zealanders.
New Zealanders deserve a strong, safe health system. Thank you.
England’s Patient Safety Commissioner, Dr Henrietta Hughes, told us when we met with her that all parts of the health system want to be at the table with her, working for a safer health system. She works collaboratively with the whole sector; drives systemic change, helps to improve the safety culture, reduce preventable harm, promote transparency and break down the barriers that exist between the health entities so they can work more effectively together. Our NZ health entities face similar barriers!
Proactive early intervention and harm prevention costs less than retrospectively treating the impact of harm. The incredible financial and human burden of harm in our health system cannot be overstated.
An independent Patient Safety Commissioner will reduce downstream health costs and ACC costs, and enable New Zealanders to live healthier more productive lives, the lives that they deserve.
New Zealanders are crying out for systemic change. We have the opportunity to be among world leaders in patient safety through the establishment of an independent Patient Safety Commissioner. This would be a be a lasting legacy for New Zealanders.
New Zealanders deserve a strong, safe health system. Thank you.