17th July 2020
Amy S Van Wey Lovatt
By email: [FYI request #12922 email]
Dear Ms Amy Van Wey Lovatt
Official Information Act (1982) Request
I write in response to your Official Information Act request, received by us on 23 June 2020, via transfer
from the Ministry of Health under section 14 of the Act. You requested the following information.
I respectfully request a list of all of the "relevant authorities" to which physicians must report
"unsafe or unethical practices", with the understanding that criminal behaviour would be included
under either "unsafe or unethical practices".
I also request a copy of all DHB policies in regards to reporting unsafe, harmful, criminal
behaviour, including the re-routing and interception of private communications, and policies on
how they document such incidents and how they are to safeguard against such incidents, as the
Operational Framework does indeed require every DHB to have such policies.
For context Counties Manukau Health (CM Health) employs over 7,500 staff and provides health and
support services to people living in the Counties Manukau region (approx. 569,400 people). We see over
118,000 people in our Emergency Department each year and over 2,000 visitors daily through
Middlemore Hospital.
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.
Our responses to your questions are below.
We cannot provide a single list of ‘all relevant authorities’ across all potential concerns of unsafe or
unethical behaviours, as relevance will be informed by circumstances.
Our expectation is that any employee with a concern about another employee’s behaviour initially raises
these concerns within our DHB line management (Service and General Managers) and/or professional
leadership (Chief Medical Officer, Chief Nurse, Chief Midwife, or Director - Allied Health.
This expectation is described in employee orientation, their professional codes of ethics, and supported
via our “Speak Up” programme. Health Practitioners can seek independent assistance or refer matters
directly to their professional Council, Registration Board or union with addressing a concern.
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
An allegation from an employee received by the DHB will first be investigated by the DHB, applying the
principles of a Just Culture (
attached); including relevant DHB management expertise and additional
advice (such as privacy, human resources, and cultural advisors), in alignment with our expectations of
the DHB Code of Conduct (
attached) and Human Resource Discipline & Dismissal Policy (
attached).
Concerns can be raised and responded to within systems outlined Incident Reporting Policy and
Procedures, or via employee supervision processes (
attached). If allegations are considered to be
sufficiently serious, these can also be escalated to the Human Resources services as a formal employee
complaint or via a Protected Disclosure process (
attached).
Should allegations be substantiated by an internal investigation, the DHB will then give formal
consideration as to appropriate sanction, and to further referral of the matter to external NZ regulatory
agency(ies), for any further censure appropriate to the issue. This may include referral of the matter to
a Professional Board, such as NZ Nursing Council or Medical Council (where the Health Practitioner
Competency Assurance Act is relevant). These bodies make publicly available their Conduct procedures,
and the outcomes of investigations.
Regarding Physicians specifically, The New Zealand Medical Association provides a set of professional
expectations, and further guidance on medico-legal matters, and Physicians can seek the NZMA’s
independent advice as to appropriate actions related to these situations.
Other government statutory agencies, including the Office of the Privacy Commissioner, Ombudsman,
Health and Disability Commission or Office of the Auditor General may also be notified or engaged to
consider a complaint from health practitioners – and they independently determine if further
investigations or action is required.
New Zealand legislation mandates that health practitioners must report relevant information related to
situations impacting Child Protection, Mental Health safety/wellbeing, Elder Abuse and Partner Violence
to statutory agencies. These arrangements are defined in law, and DHB policies align to this guidance.
Please advise us further if your query seeks these policies related to disclosure of this type.
Regarding your request for copies of all DHB policies in regards to reporting unsafe, harmful, criminal
behaviour, and policies on how they document such incidents, we provide the following Policy,
Procedure and Guideline documents (
Appendix 1). We believe these are relevant to the scope of your
request. These documents need to be considered in the overall context of our employer obligations, and
NZ Legislation.
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
Name
CM Health document owner
Deputy Chief Medical Officer (Dep CMO) & Clinical
Policy – Just Culture
Director Patient Safety, Quality Assurance
Policy – Code of Conduct
Director - Human Resources
Policy – Bullying & Harassment Prevention & Response
Director - Human Resources
Policy – Protected Disclosure
Chief legal advisor
Policy – Discipline & Dismissal
Director - Human Resources
Policy – CM Health Incident Reporting & Investigation
Chief Medical Officer (CMO) – Exec Management
Procedure – Patient Related Incident Reporting &
Chief Medical Officer (CMO) – Exec Management
Management
Policy – Privacy - Protecting & respecting personal
Risk & Privacy Manager - Strategy & Infrastructure
information
Procedure – Managing privacy breaches
Risk & Privacy Manager - Strategy & Infrastructure
Procedure – Storage & Security of Electronic & Paper Clinical
Risk & Privacy Manager - Strategy & Infrastructure
Records
Policy – Clinical Audit
Research Office - Health Intelligence & Informatics
Policy – Auditing Access to Electronic Patient Records
Chief legal advisor
Policy – Fraud Monitoring and Management
Chief legal advisor
We include a Transparency Statement and information for patient/public on requesting access to their
personal
health
information
on
our
website.
https://countiesmanukau.health.nz/about-
us/transparency-statement/
I trust this information satisfactorily answers your query. If you are not satisfied with this response you
are entitled to seek a review of the response by the Ombudsman under section 28(3) of the Official
Information Act.
Please note that this response or an edited version of this may be published on the Counties Manukau
DHB website.
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
Yours sincerely
Fepulea’i Margie Apa
Chief Executive Officer
Counties Manukau Health
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
