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8th February 2022 
 
Andrew McGregor 
Private/Individual 
Email: [FYI request #17710 email] 
Dear Andrew 
 
Official Information Act Request for – Treatment Protocols 
 
I write in response to your Official Information Act request received by us 9th December 2021 by way 
of transfer from the Ministry of Health, you requested the following information: 
  1.  Please provide Guidelines/procedure differentiating subtypes of primary (idiopathic) 
constipation 
2.  Please provide Guidelines/procedure in the treatment of patients after a suicide attempt 
and/or suicidal ideation 
3.  Please provide Guidelines/procedure for the management/prevention of persistent 
Postsurgical Pain 
4.  Please provide Guidelines/Procedures for the management of postoperative Urinary 
Retention (POUR) 
 
Counties Manukau Health Response: 
For context Counties Manukau Health (CM Health) employs over 8,500 staff and provides health and 
support services to people living in the Counties Manukau region (approx. 601,490 people). We see over 
118,000 people in our Emergency Department each year, and over 2,000 visitors come through 
Middlemore Hospital daily. 
 
Our services are delivered via hospital, outpatient, ambulatory and community-based models of care. 
We provide regional and supra-regional specialist services i.e. for orthopaedics, plastics, burns and spinal 
services.  There are also several specialist services provided including tertiary surgical services, medical 
services, mental health and addiction services. 
 
The CM Health clinical teams have access to HealthPathways which is an online manual used by clinicians 
to help make assessment, management, and specialist request decisions for over 550 conditions.  Rather 
than HealthPathways having traditional guidelines, each pathway is an agreement between primary and 
specialist services on how patients with particular conditions will be managed in the local context.   
 
1.  Please provide Guidelines/procedure differentiating subtypes of primary (idiopathic) 
constipation 
We do not have a written guideline or procedure for primary (idiopathic) constipation however 
HealthPathways has dedicated pages to assist clinicians treating for constipation in both adults 
and children.   
 
Counties Manukau Health 
 
 
Private Bag 93311, Otahuhu, Auckland  
T: 09 276 0000 | cmdhb.org.nz 
 
 
 

2.  Please provide Guidelines/procedure in the treatment of patients after a suicide attempt 
and/or suicidal ideation 
The overarching document guiding the treatment of service users after a suicide attempt and/or 
suicidal ideation is the Clinical Safety and Risk Assessment Policy (attached). In addition to the 
Clinical Safety and Risk Assessment Policy, the following list outlines some common best practice 
approaches that are undertaken: 
 
1.  A reassessment of clinical risks. This may include amending the individuals care plan in 
collaboration with the service user and family if appropriate. This includes a review of 
the treatment plan and considerations on the use of the Mental Health Act if critical 
risks have been identified. 
2.  An increased frequency of reviews by the treating team which may include the 
responsible clinician and allocated mental health clinician. 
3.  Utilising the Adverse Events Framework to determine the level of review/investigation 
needed to identify lessons to be learnt and good practice to be commended. 
4.  Utilising the Post Vention protocol which is a process that wraps support around 
individuals and close friends and family who have increased vulnerability as a result of 
the incident. 
5.  In some circumstances following phone assessments of suicidal ideation, a face to face 
assessment is undertaken immediately/ within 4 hours/ within 24 hours/ within 72 
hours. 
 
Our Mental Health Service Teams follow the Clinical Safety and Risk Assessment Policy attached 
as appendix 1. 
 
3.  Please provide Guidelines/procedure for the management/prevention of persistent 
Postsurgical Pain 
We do not have a written guideline or procedure for the management/prevention of persistent 
Postsurgical Pain.  Treatment decisions for these issues are based on clinical assessment and 
individual patient needs. 
 
4.  Please provide Guidelines/Procedures for the management of postoperative Urinary 
Retention (POUR) 
We do not have a written guideline or procedure for the management of Postoperative Urinary 
Retention (POUR).  Treatment decisions for these issues are based on clinical assessment and 
individual patient needs. 
 
I trust this information answers your request. You are entitled to seek a review of the response by the 
Ombudsman under section 28(3) of the Official Information Act.  Information about how to make a 
complaint is available at www.ombudsman.parliament.nz or Freephone 0800 802 602. 
 
Please note that this response or an edited version of this may be published on the Counties Manukau 
Health website. If you consider there are good reasons why this response should not be made publicly 
available, we will be happy to consider this. 
 
Yours sincerely 
 
 
Fepulea’i Margie Apa 
Chief Executive Officer 
Counties Manukau Health 
Clinical Safety and Risk Assessment, Safety Planning, and Risk Management with Individual Service Users Page 1 of 4
Policy: Clinical Safety and Risk Assessment, Safety Planning, and 
Risk Management with Individual Service Users
Purpose
Assisting service users and their whaanau/families to be well and safe is the central 
goal of all health services including mental health services.  Clinical risk assessment 
and management is essential in order to develop plans and interventions to achieve 
this  goal.    Risk  management  involves  developing  flexible  strategies  aimed  at 
preventing negative events from occurring or, if this is not possible, minimising the 
harm caused.
This  policy  defines  the  overarching  standards  to  be  used  in  Mental  Health  and 
Addiction  services  relating  to  safety  and  risk  assessment,  risk  management,  and 
safety planning with individual service users.  
Scope
This policy is applicable to all CM Health mental health employees, (full-time, part-
time and  casual  (temporary) including  contractors, visiting  health  professionals  and 
students working in any CM Health facility.
Policy
This policy should be considered in the context of other CM Health policies, listed at 
the end of this document. 
 Safety is the cornerstone upon which health and wellbeing is founded.
 Safety must be understood in a broad sense that encompasses all aspects of the person’s
physical, mental, spiritual, and interpersonal health.
 To assess an individual’s safety and risk, one must consider multiple factors that can act
alone or together to adversely affect the person’s health and wellbeing:
under Official Information Act
o Intentional or unintentional harm to self,
o Intentional or unintentional harm to others,
o Environmental and situational risks,
o Medical and physical vulnerability,
o Risks associated with substance use/abuse,
Released 
o Risks associated with neglect of needs (self or others)
o Socioeconomic vulnerability,
o Risks associated with  MH relapse,
o Vulnerability to harm by others,
o Legal risks and vulnerability to rights violations,
o Risks associated with cultural factors including racism,
o Risks associated with treatment.
 Safety planning must directly involve the service user, the family/whaanau, and natural
systems of supports.  The service user and their whaanau/family must understand how
Document ID:
A11565
CMH Revision No:
3.0
Service:
Mental Health Services
Last Review Date :
26/02/2019
Document Owner:
Clinical Director - Mental Health Services
Next Review Date:
25/02/2022
Approved by:
Clinical Governance Group (CGG)
Date First Issued:
23/10/2009
If you are not reading this document directly from the Document Directory this may not be the most current version
Clinical Safety and Risk Assessment, Safety Planning, and Risk Management with Individual Service Users Page 2 of 4
treatment recommendations support the person’s safety and wellbeing, and why they are 
important. 
 Service users and their whanau/ family must be provided with education and information 
in a manner that enables them to support the persons safety and wellbeing
 Assessment of safety and risk also entails an assessment of the person’s strengths, 
resources, resilience, and other protective factors that can be built upon to increase his or 
her wellbeing and safety.
 Safety assessment and safety planning are part of an on-going cyclical process to improve 
health and wellbeing and to minimise harm.  This is accomplished through a continuous 
systematic refinement of the individual’s plan.  The cycle consists of assessment, safety 
planning, implementation, monitoring of outcomes, then re-assessment and repetition of 
this process.
 Safety assessment and planning must occur within the context of the individual’s cultural 
background and social situation.
 Risk is influenced by both static and dynamic factors and, therefore, can change rapidly 
and radically.
 Safety planning must reflect principles of healthful, positive risk-taking.
 Safety assessment, safety planning and monitoring of outcomes should use validated 
tools whenever possible.
Fundamentals of Clinical Safety and Risk Assessment
When approaching clinical risk assessment and management CM Health Integrated Mental 
Health  &  Addictions  Services  endorses  the  UK  Department  of  Health’s  Best  Practice  in 
Managing Risk, (March 2009) underlying principles:
 Best  practice  involves  making  decisions  based  on  knowledge  of  the  research  evidence, 
knowledge of the individual service user and their social context, knowledge of the service 
user’s own experience, and clinical judgement.
under Official Information Act
 Positive risk management as part of a carefully constructed plan is a required competence 
for all mental health practitioners.
 Risk  management  should  be  conducted  in  a  spirit  of  collaboration  and  based  on  a 
relationship between the service user and their carers that is as trusting as possible.
Released 
 Risk management must be built on recognition of the service user’s strengths and should 
emphasise recovery.
o These principles have important implications for clinical practice. Assessment of safety 
and risk is conducted at each and every point of contact with the service user and/or 
whaanau/family.  It is an integral part of every clinical observation.
Document ID:
A11565
CMH Revision No:
3.0
Service:
Mental Health Services
Last Review Date :
26/02/2019
Document Owner:
Clinical Director - Mental Health Services
Next Review Date:
25/02/2022
Approved by:
Clinical Governance Group (CGG)
Date First Issued:
23/10/2009
If you are not reading this document directly from the Document Directory this may not be the most current version
Clinical Safety and Risk Assessment, Safety Planning, and Risk Management with Individual Service Users Page 3 of 4
Safety Assessment and Planning
 Safety  includes  the  safety  of  the  service  user,  whaanau/family  and  other  natural 
supports, other service users, staff, and the community.
 When factors that affect safety adversely are identified (e.g., drug use, inconsistent 
treatment), these are discussed with the service user and the whaanau/family and a 
plan  for  intervention  is  addressed.    As  appropriate,  the  safety  plan  will  be  further 
developed by multidisciplinary or multiagency teams. 
 Safety assessment and planning within treatment teams should be conducted in an 
open, equal, and transparent manner that embraces reflective practice. 
 Concerns and findings regarding safety and risk are documented  
 Concerns and findings must be communicated to others involved in the 
services to the individual (e.g., team members, carers, GP) as soon as is 
practicable. 
 Clinical  interventions  will  appropriately  reflect  the  acuity  of  risks  that  are 
Act
identified  and  adhere  to  best  practices.  The  effectiveness  of  the  service 
user’s safety plan is evaluated regularly, and safety and risks for service users, 
staff, and others are regularly reviewed.  Appropriate changes to the safety 
plan  are  made  using  the  assessment  - safety  planning  – implementation  -
monitoring  of  outcomes  – re-assessment  cycle.    Changes  to  the  safety 
assessment and plan are documented clearly and timely.
Information 
 Shortfalls in services and unmet needs are identified and addressed
 Plans are  developed to support safety and mitigate risk as the service user 
engages  in  healthy  risk-taking  as  a  part  of  her/his  personal  growth  and 
recovery,  this  is  documented  in  the  Relapse  Prevention  Plan  (or  similar) 
Official 
document
 All staff will implement safety assessment and planning with sensitivity and 
competence in relation to diversity in ethnicity, faith, age, gender, disability 
and sexual orientation.
under 
 Risk management will include an awareness of the capacity for the service 
user’s risk level to change over time, and a recognition that each service user 
requires a consistent and individualised approach.
 Safety  assessment  and  planning  will  incorporate  the  perspectives  of  the 
service user’s whaanau/family and carers.
Released 
Implementation and levels of responsibility
The Integrated Mental Health & Addictions Clinical Governance Group is responsible for 
monitoring implementation of and compliance with this policy.
All managers of clinical teams are responsible for ensuring staff who report to them are 
familiar with this policy: 
 The implementation of safety and risk assessment and management procedures
 Support for monitoring, documentation, communication, and reporting in relation 
to risk assessment and management
Document ID:
A11565
CMH Revision No:
3.0
Service:
Mental Health Services
Last Review Date :
26/02/2019
Document Owner:
Clinical Director - Mental Health Services
Next Review Date:
25/02/2022
Approved by:
Clinical Governance Group (CGG)
Date First Issued:
23/10/2009
If you are not reading this document directly from the Document Directory this may not be the most current version
Clinical Safety and Risk Assessment, Safety Planning, and Risk Management with Individual Service Users Page 4 of 4
 Supporting activities that will inform the continuous process to improve practice 
Staff Training and Support
Training  will  be  available  for  all  staff  who  are  involved  in  the  assessment  and
management of clinical risk:
All  new  practitioners  must  attend  Safety  Planning  and  Risk  Assessment  Training  within 
three months of starting at CMH mental health and addiction services.
All  existing  practitioners  should  attend  refresher  training  as  frequently  as  deemed 
appropriate by their manager.
Consultation, Approval and Ratification Process
This  policy  was  been  written  and  subsequently  reviewed  by  the  Risk  Assessment  & 
Management  Policy  Review  Group  consisting  of  (Managers  representatives  and 
Clinicians). 
The policy has been ratified by the Integrated Mental Health & Addictions Service Clinical 
Governance Group.
Act
Policy Compliance Monitoring Process
Staff feedback, service user feedback, audit, 
CMDHB Policies and 
http://southnet/riskmanagement/Process.htm
Procedures
Staff Critical Incident defusing and debriefing policy
CMDHB Patient and Whaanau Centred Care Programme
Information 
Mental Health Services Service User and Family/Whaanau Participation 
Policy
NZ Legislation / National 
NZ Guidelines for managing Risk 
Official 
– MOH 1998
Standards / Programmes
Assessment and Management of Risk to Others MH Workforce 
Development Programme Trainee Workbook  (MOH and HRC, NZ)2006
under 
Health and disability services Standards - Health and disability services 
(core) Standards NZS 8134.1:2008
National Incident Management Programmes 
(http://nzsip.communiogroup.com/)
Released 
Document ID:
A11565
CMH Revision No:
3.0
Service:
Mental Health Services
Last Review Date :
26/02/2019
Document Owner:
Clinical Director - Mental Health Services
Next Review Date:
25/02/2022
Approved by:
Clinical Governance Group (CGG)
Date First Issued:
23/10/2009
If you are not reading this document directly from the Document Directory this may not be the most current version

Document Outline