Ryall Tony: Questions for Oral Answer — Questions to Ministers 
Ryall Tony: Questions for Oral Answer — Questions to Ministers 
[Volume:675;Page:14386] 
5.  
Hon TONY RYALL (National—Bay of Plenty) 
 to the  
Minister of Health 
: What action if any did the Government take to implement a national standardised sentinel events reporting system as recommended by the Sentinel Events Project Working Party in 2001? 
Hon DAVID CUNLIFFE (Minister of Health) 
: 
 First let me note my concern that when a serious issue such as sentinel events is raised some people put the lives of those who have been touched by these events second and their own agendas first. Politicians may argue the details but real lives have been affected and we need to respect that when entering debate. Since 2001 the Ministry of Health has been working closely with the district health boards on training in reporting sentinel events and more important on how to put procedures in place to learn from those events. The first guidelines in this area were published in September 2001. 
Hon Tony Ryall 
: Why did the Government fail to set up a national system when that was recommended in this 2001 report and recommended in four reports of the current Health Committee and why after the Government sitting on this report for 7 years should New Zealanders have any confidence that this Government will make our hospitals safer? 
Hon DAVID CUNLIFFE 
: I am advised that the presumption in the member’s question is incorrect. Since 2001 the Government set up in 2003 an audit system based on HealthCERT to improve the efficacy of individual hospital reviews and those certifications occur at a minimum every 3 years; the district health boards have been implementing local information technology reporting systems and building infrastructure; the Government further set up in 2004 the National Health Epidemiology and Quality Assurance Advisory Committee—EpiQual—which was established in particular to look at mortality and morbidity reviews; and in February 2007 the Quality Improvement Committee was established to take over that work and a budget of some $20 million was allocated to further its work in the sector. 
Lesley Soper 
: Why is the Minister supportive of today’s release of information pertaining to serious and sentinel events? 
Hon DAVID CUNLIFFE 
: It is through transparency that we achieve improvement. Today’s announcement is a watershed moment in health. It recognises the fact that those are areas we need to improve in. In order to make those improvements we need to look openly and honestly at all the information and be prepared to learn from those events. 
Sue Kedgley 
: Does not the release of the data today really just show that the entire system for the reporting of adverse events is still a shambles with different district health boards using different systems different reporting requirements and different definitions and with some choosing not to report at all; and given that the entire system is still voluntary meaning it is up to the district health boards to decide whether and what they choose to report if at all and given the fact that the Health Committee this morning was given completely different data on adverse events by Capital and Coast District Health Board from what was reported today how can we have confidence in the figures that have just been released? 
Hon DAVID CUNLIFFE 
: I am advised that since the publication of guidelines in 2001 the effort of the Ministry of Health was about building capability in district health boards and working with each of them to set up their own systems. I am further advised that the function of the HealthCERT division of the ministry has been around individual district health board review processes. However I agree with the member that an opportunity exists from here forward to ensure ongoing national consistency of data collection and reporting and that will happen. 
Hon Tony Ryall 
: Does the Minister realise that this is the tip of the iceberg with his own officials admitting today that many more serious and fatal events have not been included in these numbers and that some district health boards are unable even to collect these numbers; and what does it do for the public’s confidence in the health system when no one actually knows how many people are dying needlessly? 
Hon DAVID CUNLIFFE 
: Let us reflect on what these statistics are and are not. They are a 1-year snapshot of the year 2006-07 with 2.2 in every 10000 hospital admissions resulting in a serious or sentinel event. They are different from adverse event reporting which is a broader pool and I am advised that the Quality Improvement Committee and the Ombudsman are comfortable with the national set of standards that is being used to pull these together. 
Sue Kedgley 
: Why is the Waikato District Health Board the only district health board that has clearly reported on the number of deaths—23—caused by its action or inaction last year and can he help the members of this House by telling us now clearly and unequivocally how many people died last year and how many people became permanently disabled as a result of an action or an inaction by a district health board? 
Hon DAVID CUNLIFFE 
: Data according to the consistent definitions worked through by the Quality Improvement Committee was released this morning. I agree with the member that the time has come to ensure going forward that there are nationally consistent definitions nationally consistent data reporting and nationally consistent monitoring of systems. 
Sue Kedgley 
: I raise a point of order Madam Speaker. I do not think I could have been more plain with my question which was how many people died and how many people became disabled last year as a result of actions— 
Madam SPEAKER 
: The Minister did address the question. 
Sue Kedgley 
: He did not answer the question as to how many people died. 
Madam SPEAKER 
: Would the member please be seated. The member knows full well what the Standing Orders say. The Minister must address the question; the Minister addressed the question. 
Hon Tony Ryall 
: Does the Minister realise that he just said that the time had come for nationally consistent data and for nationally consistent reporting yet that is the very thing that was recommended to Annette King in 2001? When New South Wales brought in a system to monitor this matter it saved lives. This Government has done nothing and what explanation does it have for that? 
Hon DAVID CUNLIFFE 
: May I repeat for the member’s benefit that in 2001 a set of guidelines was published and the district health boards were assisted to follow them. However the review process of the district health boards was on an individual basis. I have already agreed with the member opposite Sue Kedgley that more can be done to ensure nationwide consistency in implementation and monitoring and it will be done. 
Hone Harawira 
: Tena koe Madam Speaker. Tena tatou katoa e te Whare. What action if any has the Government taken in response to Professor Peter Davis’ 2006 paper in  
The Lancet 
 which showed that Maori patients received a lower standard of care in hospital than other New Zealanders and were more likely to suffer adverse effects? 
Hon DAVID CUNLIFFE 
: The Davis report has fed into the ongoing work of the Quality Improvement Committee which has five key work streams and on which I am expecting a further briefing very shortly. I have signalled that this issue is a priority for action and I have linked that action to the district health boards’ receiving their full budgets in the coming year. The member raises a very important point. During the lost decade of the 1990s Maori suffered more than any other part of our community did from the explosion of disparities in living standards and health outcomes in this country and that situation must never be allowed to be repeated. 
Hon Tony Ryall 
: Does the Minister stand by his press statement of earlier today which stated that on the basis of this information New Zealand’s hospitals compared favourably with Australian and American hospitals when his own officials admitted today at the press conference and in Parliament’s Health Committee that we simply cannot rely on this information for any comparison whatsoever? 
Hon DAVID CUNLIFFE 
: Absolutely I stand by that in two respects. Firstly the Davis study is on a like-for-like basis with comparable studies made available to us through the Commonwealth Fund and secondly those studies show that New Zealand compares very well with countries like Australia and the United States in that we have a lower rate of adverse events. 
Hone Harawira 
: What action if any has the Government taken in response to Professor Peter Davis’ recommendation in the same 2006  
Lancet 
 study that data should include patients’ ethnicity; and can he tell the House why he is unable to tell us how many people actually died in hospital last year as a result of action or inaction by any of the district health boards? 
Hon DAVID CUNLIFFE 
: In respect of the first part of the question it is my understanding that patients’ ethnicity is currently collected. In respect of the second part I will verify the contention and get back to the member. 
Hon Tony Ryall 
: What is going on in our hospitals when the Health and Disability Commissioner says they are unsafe and these documents today show that basic care is being neglected and New Zealanders are dying needlessly; and is that what the people were expecting when they put Helen Clark in charge in 1999? 
Hon DAVID CUNLIFFE 
: What is going on in our hospitals is that around the country dedicated clinicians are seeking to make New Zealanders well. What is going on in our hospitals is that the Government has invested substantially more in facilitating those outcomes to occur. And what is going on in our hospitals is work that needs to continue without the petty point-scoring of the Opposition spokesman. 
Hone Harawira 
: I seek leave to table an article “Quality of hospital care for Maori patients in New Zealand: retrospective cross-sectional assessment” by Professor Peter Davis and six other writers. 
Document by leave laid on the Table of the House. 
Sue Kedgley 
: I seek leave to table information from the financial review today of the Capital and Coast District Health Board by the Health Committee that gives completely different data. 
Document not tabled. 
Hon Tony Ryall 
: I seek leave to table the report from the Sentinel Events Project Working Party to the Director-General of Health in 2001 that recommended setting up a national standardised system for sentinel events. 
Document not tabled. 
Hon Tony Ryall 
: I seek leave to table the Health Committee’s 2004-05 financial review of the Ministry of Health calling for a national standard on sentinel reporting. 
Document not tabled. 
Hon Tony Ryall 
: I seek leave to table the 2005-06 financial review of the Ministry of Health calling for priority to be given to the setting up of a national mandatory reporting system on sentinel events. 
Document not tabled. 
Hon Tony Ryall 
: I seek leave to table yet another report calling for action on sentinel events—the Vote Health estimates for 2006-07. 
Document not tabled. 
Hon Tony Ryall 
: I seek leave to table another call for information on hospital-related adverse events to be standardised and nationally reported—the Vote Health estimates for 2007-08. 
Document not tabled. 
Hon DAVID CUNLIFFE 
: I seek leave to table a statement made by the New Zealand nurses association supporting today’s disclosure of serious and sentinel events. 
Document by leave laid on the Table of the House. 
Hon DAVID CUNLIFFE 
: I seek leave to table a statement made by the New Zealand Medical Association welcoming the release of today’s report. 
Document by leave laid on the Table of the House. 
Madam SPEAKER 
: I remind members that there is to be silence when members are seeking leave. It is very difficult for members to hear in order to judge whether to raise objection.