Dear Capital and Coast District Health Board,

This is an Official Information Act request.

Please provide to me (via an electronic record) details of what audits have been undertaken of Wellington Hosptial's Te Whare o Matairngi over the three year period between 1st Nov 2013 and 31st Oct 2016

Yours faithfully,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Please forward an acknowledgement to Mr Nigel Fairley (General Manager, 3DHB Mental Health, Addictions and Intellectual Disability Services), for his 29.08.18 letter in response to this Official Information Act (OIA) request.

For the record, here is the Text specific to this OIA request for 'Audits of Wellington Hosptial's Te Whare o Matairngi' which is Appended from Mr Fiarley's letter received by email on 29.08.19.

Dear Mr Wild....

OIA request 2019-164 (CCDHB designated reference number).

"We are currently looking into this request"

Regards
Nigel Fairley
MHAIDS.

I look forward to a response pursuant to CCDHB's obligations under the Official Information Act 1982.

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for your email.

It did not include any attachment contrary to your assertion that it did.

As you posted your email on this webpage I assume you are requesting a 10 day extension for this OIA request 'Audits of Wellington Hosptial's Te Whare o Matairngi' but this is unclear.

Please confirm pursuant to the Official Information Act 1982, which OIA are you requesting a 10 day extension for.

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for todays confirmation of a request for a 10 day extension to this OIA on grounds which CCDHB determines to be that the request "involves a large quantity of information"

I believe the amount of information specific to this request is a reasonable quantity of information to request pursuant to the Official Information Act.

If on receipt of the information I am correct in this assumption I will raise a complaint via the Ombudsman Office on the grounds that CCDHB will have breached its obligations to the aforementioned legislation

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for todays confirmation of a request for a 10 day extension to this OIA on grounds which CCDHB determines to be that the request "involves a large quantity of information"

I believe the amount of information specific to this request is a reasonable quantity of information to request pursuant to the Official Information Act.

If on receipt of the information I am correct in this assumption I will raise a complaint via the Ombudsman Office on the grounds that CCDHB will have breached its obligations to the aforementioned legislation

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for your 27.09.19 email confirming the following audits as having taken place at Te Whare o Mataraangi between 1.11.13 and 31.10.16:

- Pharmaceutical fridge - daily temperature log {done Daily)
- Pharmaceutical fridge maintenance and cleaning log (Done weekly)
- Resuscitation trolley emergency equipment check {Done weekly)
- Defibrillator check (Done weekly)
- Hand hygiene audit-August 2014, May 2016
- Controlled Drug Check - Done weekly
-Controlled Drug Stock Take - Done weekly
- Environmental cleaning and maintenance - service walk through - February 2015
- Health & Safety - planned general inspection by line managers to identify new hazards - December 2013
- MHAID Consumer Information Audit-April 2016, August 2015
- MHAID Inpatient Services Ligature Audit- 2015, 2016
- MHAID Metabolic Monitoring Audit - June 2016
- Medication Administration Audit - January 2013
- Infection Control Audit - July 2014

The identified audits are limited to primarily environmental audits. The audits you have listed omit audits of staff, including competency audits and staffing level audits, the way patients are cared for, how the staff interact with patients, clinical records, and policies and procedures.

As per the legislated requirements and the CCDHB Open Disclosure Policy, please release pursuant to the Official Information Act a list of all audit requirements that are additional to the those you have identified, that Te Whare o Mataraangi were obligated to undertake between 1.11.13 and 31.10.16

To prevent further delay, and to assist you I have simplified this request to be a list of required audits rather than those actually undertaken

The purpose of this request is to assist a number of families who have requested my assistance in matters related to several Serious Adverse Events at Wellington Hospital.

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for the details of some of the audit obligations you have identified as being required at Te Whare o Mataairangi during the period 1st Nov 2013 and 31st Oct 2016

Please clarify your response by confirming whether or not audits referenced in relation to a 2012 Coroners case (Coroner Ref: CSEU-2012-WGTN-000285) were undertaken during the period specified, as recommended by the statutory Serious Adverse Event Review Team:

"CCDHB to Audit practice in relation to":
1) "the recommendations made in respect to areas of practice and at a frequency determined by CCDHB mental health patient safety group meeting
2) "Routine review of all resuscitation incidents by a suitably qualified resuscitation expert with feedback to staff and the unit/service involved in the resuscitation"

Yours sincerely,

Mr Wild

Dear Robyn Fitzgerald [CCDHB],

Thank-you for forwarding Nigel Fairley's 04.10.19 response which for the interests of transparency I have copied and inserted below, Yours sincerely, Mr Wild

Response:

We believe that we properly and comprehensively responded to your earlier request for information regarding audits. We comment below on each of the areas you suggest we omitted to provide information on.

1. Audits of staff, including competency audits

Staff are required to demonstrate competencies in various areas (e.g. CPR) and to undertake ongoing training and education. However, a staff member's clinical practice is not audited.

2. Staffing level audits

Staffing levels are monitored and managed. MHAIDS has tools in place which assess acuity levels and calculate the desirable staffing numbers required e.g. TrendCare. Generally speaking, we do not undertake audits of staffing levels.

3. The way patients are cared for

It is not entirely clear what you mean when you suggest that the 'way patients are cared for' is audited.

The following are examples of audits undertaken by DHBs (not all of which are undertaken specifi call y within MHAIDS}:

¥ Completion of falls assessments and individual care plans based on the risks identified;
¥ Completion of skin integrity assessments, individual care plans base d on the risks identified, and the identification of pressure injuries;
¥ Compliance with hand hygiene;
¥ % of healthcare associated staphylococcus aureus bacteraemia per 1000 bed days;
¥ Incidents of central line associated bacteraemia (CLAB);
¥ Rate of in-hospital cardiopulmonary arrests per 1000 admissions;
¥ % of patients who triggered an escalation of car e and received the appropriate response;
¥ % of patient with early warning scores calculat ed correctly;

The audit results can be accessed at the following websit e: htt ps:/ / www.hq sc.govt.nz/ our­ programmes/ healt h-qualit y-evaluat ion/ projects/ qualit y-and-safety-markers/

DHBs are also audited against cert ai n performance measures. This information, as it relates to mental health services, can be found at:
htt ps:/ / nsfl.healt h.go vt.nz/ acco untability/ perfo rmance-an d-monitoring/ mental-healt h-alcohol-an d­ drug-addiction-sector

4. How the staff int eract with patients

There is a Natio nal M ent al Health Consumer Satisfaction Survey which elicits consumers ' views on how they felt t heyw ere treated/interacted with. However , this does not, in our view, fall within the
defi nit ion of an au dit.

5. Clinical records

For the time period request ed, digital client records were still under development and were not universally used by all services. Audits were undertaken of paper based clinical records. However, it appears that the documents relating to such audits have not been retained and no longer exist.

6. Policies and procedures.

Generally, there is no systematic audit against our policies and procedures, except as outlined in the audit schedule. From time to time, after a policy has been implemented, a follow-up audit may be commissioned to identify compliance. Policies and procedures are reviewed and updated in accordance with our Controlled document development and review policy (attached for your information)

Our services are, of course, also reviewed by external agencies in the context of (for example), hospit al certification; inspection by the Ombudsman of mental health service places of detention; invest igat ions by District Inspectors; investigations by the Health and Disability Commissioner and so on.

We trust the information we have provided meets your needs. As you are aware , you have the right, by way of complaint under section 28(3) of the Official Information Act 1982 to the Office of the Ombudsman, to seek an investigation and review of any refusal to disclose info rm ati on to you. Further information about making a complaint can be found at http:/ / www.ombudsman.parliament.nz/ make­
a-comp laint.

regards,

Nigel Fairley
General Manager

Dear Robyn Fitzgerald [CCDHB],

Thank-you for forwarding Nigel Fairley's 04.10.19 response which for the interests of transparency I have copied and inserted below, Please note I am still awaiting my previous 07.10.19 response to confirm whether or not audits referenced in relation to a 2012 Coroners case (Coroner Ref: CSEU-2012-WGTN-000285) were undertaken during the period specified, as recommended by the statutory Serious Adverse Event Review Team:

"CCDHB to Audit practice in relation to":
1) "the recommendations made in respect to areas of practice and at a frequency determined by CCDHB mental health patient safety group meeting
2) "Routine review of all resuscitation incidents by a suitably qualified resuscitation expert with feedback to staff and the unit/service involved in the resuscitation"

Yours sincerely, Mr Wild

______________________________________________________________________________________

CCDHB's partial response:

We believe that we properly and comprehensively responded to your earlier request for information regarding audits. We comment below on each of the areas you suggest we omitted to provide information on.

1. Audits of staff, including competency audits

Staff are required to demonstrate competencies in various areas (e.g. CPR) and to undertake ongoing training and education. However, a staff member's clinical practice is not audited.

2. Staffing level audits

Staffing levels are monitored and managed. MHAIDS has tools in place which assess acuity levels and calculate the desirable staffing numbers required e.g. TrendCare. Generally speaking, we do not undertake audits of staffing levels.

3. The way patients are cared for

It is not entirely clear what you mean when you suggest that the 'way patients are cared for' is audited.

The following are examples of audits undertaken by DHBs (not all of which are undertaken specifi call y within MHAIDS}:

¥ Completion of falls assessments and individual care plans based on the risks identified;
¥ Completion of skin integrity assessments, individual care plans base d on the risks identified, and the identification of pressure injuries;
¥ Compliance with hand hygiene;
¥ % of healthcare associated staphylococcus aureus bacteraemia per 1000 bed days;
¥ Incidents of central line associated bacteraemia (CLAB);
¥ Rate of in-hospital cardiopulmonary arrests per 1000 admissions;
¥ % of patients who triggered an escalation of car e and received the appropriate response;
¥ % of patient with early warning scores calculat ed correctly;

The audit results can be accessed at the following websit e: htt ps:/ / www.hq sc.govt.nz/ our­ programmes/ healt h-qualit y-evaluat ion/ projects/ qualit y-and-safety-markers/

DHBs are also audited against cert ai n performance measures. This information, as it relates to mental health services, can be found at:
htt ps:/ / nsfl.healt h.go vt.nz/ acco untability/ perfo rmance-an d-monitoring/ mental-healt h-alcohol-an d­ drug-addiction-sector

4. How the staff int eract with patients

There is a Natio nal M ent al Health Consumer Satisfaction Survey which elicits consumers ' views on how they felt t heyw ere treated/interacted with. However , this does not, in our view, fall within the
defi nit ion of an au dit.

5. Clinical records

For the time period request ed, digital client records were still under development and were not universally used by all services. Audits were undertaken of paper based clinical records. However, it appears that the documents relating to such audits have not been retained and no longer exist.

6. Policies and procedures.

Generally, there is no systematic audit against our policies and procedures, except as outlined in the audit schedule. From time to time, after a policy has been implemented, a follow-up audit may be commissioned to identify compliance. Policies and procedures are reviewed and updated in accordance with our Controlled document development and review policy (attached for your information)

Our services are, of course, also reviewed by external agencies in the context of (for example), hospit al certification; inspection by the Ombudsman of mental health service places of detention; invest igat ions by District Inspectors; investigations by the Health and Disability Commissioner and so on.

We trust the information we have provided meets your needs. As you are aware , you have the right, by way of complaint under section 28(3) of the Official Information Act 1982 to the Office of the Ombudsman, to seek an investigation and review of any refusal to disclose info rm ati on to you. Further information about making a complaint can be found at http:/ / www.ombudsman.parliament.nz/ make­
a-comp laint.

regards,

Nigel Fairley
General Manager