Lessons learned, says Te Whatu Ora


The foundation of the Health and Disability Commissioner system is that clinicians and healthcare providers learn from their mistakes.

Te Whatu Ora-Southern quality and clinical governance solutions executive director Hywel Lloyd said that the organisation – formerly the Southern District Health Board – had done its level best to accept what was a damning report into the death of Wendy Fraser, and then show demonstrable improvement.

‘‘We had to reflect on our failings in this case and we’ve got procedures and processes in place so that the chances of that ever happening again are significantly reduced and minimised.’’

Senior executives have met Mrs Fraser’s family throughout the complaint process, regularly apologised, and kept the family informed of what the organisation was doing to implement the report’s recommendations.

‘‘Events of this level are, thankfully, rare,’’ Dr Lloyd said.

‘‘But when something does go wrong we have to make sure that it doesn’t happen again.’’

To that end, assessing Korero Mai and seeking to implement its philosophy has been of vital importance, Dr Lloyd said.

‘‘It is very well recognised with health that there is a power imbalance, based on knowledge… we have done a lot of work with clinicians as to whether they are acknowledging that power imbalance and whether they are adjusting their conversation so that it is much more collaborative and that they listen to patient or consumer concerns, particularly if the person is not doing well or their condition is deteriorating.’’

Korero Mai was now a nationally accepted programme and it fitted in well with improvements that the southern health system already had under way, Dr Lloyd said.

‘‘Korero mai means speak up, and we want people to feel that they can do that and they don’t feel that they are in any way impeded from doing so.’’

There had been some operational hurdles to clear, such as when Covid-19 restricted visitors to wards, but in general families should always be welcome to play a part in caring for their loved ones on the ward, Dr Lloyd said.

‘‘Covid was a difficult time but generally we encourage family and whanau to come, it’s a really important part of someone’s care, and the operational issues aren’t too great.’’ 

[email protected] 

Leave a Comment