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Mental Health Service Review

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An external review of the whole Mental Health Service was completed in 2014 with changes to services recommended.


Two serious adverse events occurred within a short period of time in the acute mental health inpatient unit at Palmerston North Hospital (Ward 21). The events were the apparent self-inflicted deaths of two inpatients, three weeks apart. These two events were tragic outcomes for those patients and MDHB senior management on behalf of staff wish to express deepest sympathy to the families. It is also acknowledged that the issues that have arisen regarding the care provided and the functioning of the mental health service have had a profound and distressing impact on both families and the wider community.
At the request of the Board, and in consultation with the Ministry of Health’s Director of Mental Health, it was determined that a wide external systematic review of the service as a whole be instigated, referencing the two events.  The external review was commissioned in June 2014 to ensure that any underlying issues in relation to the structure, resourcing, or culture of the service be identified and addressed. The review was completed in August 2014 and presented at the MDHB Hospital Advisory Committee September 2014 meeting.
A number of recommendations were identified and a work programme has been developed to address these. The MDHB Hospital Advisory Committee will be provided with updates and progress.

Key Documents



​Document Format

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General information about Palmerston North Hospital.