To be attributed to Phil Grady, Health New Zealand National Director, Mental Health and Addictions

Health New Zealand acknowledges significant failings identified in the Ministry of Health’s report on Canterbury | Waitaha adult in-patient mental health services and is committed to implementing the recommendations of Dr John Crawshaw, Director of Mental Health, Clinical, Community and Mental Health, to prevent the tragic events of 2022 and 2024 from happening again.

We recognise the loss and grief these families have and continue to experience and express our sincere condolences to them. We are deeply sorry for the failings in our systems.

We have reached out to these families to apologise and discuss Dr Crawshaw’s report, and will remain in contact, if that is their choice, to update them on progress to implement actions from the report.

We accept all of Dr Crawshaw’s findings and have an action plan in place to implement the recommendations, which focused on the underlying issues related to governance, the care model, and resourcing.

We are focused on continuing to provide senior leadership oversight of planning for the service, building a framework, and ensuring there is sufficient staff with the right level of training and experience to safely and effectively deliver services.

As noted in Dr Crawshaw’s report there has been demonstrable progress on key recommendations:

  • There is a clinical governance framework in place.
  • Clinical staffing has increased by 11 percent since 2022.
  • Clinical decision making on patient leave is consistent with policies and there are weekly audits of compliance in place.

There are clear pathways both within the service and nationally within Health New Zealand to escalate and manage risk.

In addition to recommendations identified in the report, we have already made the following improvements to embed regional planning, decision making and information flow, increase staff recruitment, upskilling and training across the service, develop a cultural narrative to include a te ao Māori perspective, and upgrade a range of facilities.

To ensure progress of the recommendations continue, we welcome Dr Crawshaw’s increased oversight of the service over the next 12 months.

We are committed to improving the service and our actions will be closely measured against this report, and two other event reviews conducted by Health New Zealand.

Section 99 inspection of Canterbury Mental Health Services — Ministry of Health (external link)