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Review of Hillmorton’s Adult Inpatient Service


DATE: 18.8.08

SUBJECT: Review of Hillmorton’s Adult Inpatient Service Completed

The review of the Acute Inpatient Service (AIS) at Hillmorton Hospital has been completed. Canterbury District Health Board will now look at its recommendations and consider what changes need to be made to the AIS.

CDHB’s Chief Psychiatrist Associate Professor Phil Brinded said the report had been discussed with staff and the families of three patients who died in the Unit early this year. He said the comprehensive investigation into AIS is just what had been hoped for in doing the review and laid a foundation for meaningful service changes and development.

“We were very concerned at the tragic deaths of three inpatients at Hillmorton earlier this year and wanted to take a very close look at the circumstances surrounding them and whether anything further could have been done to prevent them,” he said.

As with all serious events in Canterbury hospitals, each of the patients’ deaths prompted an internal Sentinel Event Review. They will also be reviewed as part of the coronial process. The Sentinel Event Review process involves a thorough investigation and analysis of each incident resulting in recommendations to improve future patient care. The CDHB is in the process of addressing the recommendations in these reviews.

The aim of the independent review was to take a much wider look at the service structure and context in which the patient deaths occurred. Admission, assessment, treatment, discharge planning processes and relationships with Adult Community Services were a focus of the review team, headed by Professor Graham Mellsop The report has two over arching recommendations. The first advocates greater integration of the mental health sector and that the provision of mental health services be planned by representatives from throughout the sector. The second advises possible reconfiguration of beds in the Specialist Mental Health Service.

Across Canterbury, it recommends an increase in the number of beds in the AIS and a decrease in the number of inpatient rehabilitation beds.

CDHB’s General Manager Vince Barry says that the number and level of occupancy of acute mental health beds in Canterbury is on a par with other parts of the country. “Many of the issues raised are not exclusive to Canterbury but we will certainly be looking at the number and type of beds that are available to do our very best to improve patient welfare and staff effectiveness."

Assoc Prof Brinded said the review points a way forward for acute psychiatric services in Canterbury.

“It describes improvements to service delivery that can be enacted in the near future as well as the medium term. From it, we can look to achieving continuous improvements in the service, while acknowledging that it is the staff who will be instrumental in effecting change,” he said.

“We are committed to providing the very best mental health services we can, delivered safely, effectively and efficiently to the people of Canterbury. As such, we will encourage the planning, implementation and evaluation of the recommendations in this report as soon as practicable."


An executive summary of the independent review is attached to this release.

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