Canterbury health services reported 47 serious adverse events over six months, including 24 falls resulting in fractures or head injuries, according to Health New Zealand’s first national report.

The report covers Hospital and Specialist Services between 1 July and 31 December 2025 and outlines changes being made after patients suffered serious harm.

Canterbury recorded 20 events involving clinical processes or procedures, a category that includes pressure injuries. Other reported incidents involved medication or intravenous fluids, and resources or organisational management.

Across the South Island, 112 serious adverse events were reported, including nine in South Canterbury.

Nationally, Health NZ recorded 440 serious adverse events across more than 683,000 hospital discharges. In 59 of those cases, the patient died.

The national reporting rate was 6.44 serious adverse events per 10,000 discharges, with no significant change in reported rates since 2023.

Health NZ executive national director clinical Dr Richard Sullivan apologised to those affected.

“Every serious adverse event has affected a person, their whānau, family and community. Health NZ sincerely apologises to every person, whānau, family, carer and friend affected by a serious adverse event, and we are sorry for the harm and distress people have experienced,” Sullivan said.

The report identifies several safety improvements in Canterbury following reviews of patient harm.

These include reviewing carpets for trip hazards, checking medical review processes in residential settings, and ensuring individual safe mobility plans are accurately documented and reflected in the care patients receive.

To reduce pressure injuries, Canterbury services are reviewing observation charts to include checks beneath medical devices and over bony areas of the body.

The report also outlines the purchase of equipment intended to prevent pressure injuries beneath masks and devices securing feeding tubes, alongside a review of how skin assessments and prevention measures are documented and carried out.

In South Canterbury, a patient safety programme piloted in a medical ward resulted in a reported 75 percent reduction in falls. It was extended across all wards and units in January 2026.

The report also highlights delays in completing South Island investigations into serious harm.

For reviews due for completion during the reporting period, the region recorded 35 percent compliance with the required timeframe of 120 working days.

Health NZ attributed delays to rising workloads, limited quality and patient safety capacity, reduced availability of clinical teams prioritising direct patient care, and complex engagement with patients and families.

The review figures reflect data reconciled on 10 February 2026. Further reviews may have been completed since then, and the report notes that safety improvements can begin before an investigation is finished.

Health NZ cautioned against using raw event numbers to compare the safety of different districts. Patient volumes, the complexity of care and reporting practices can all influence the figures.

Christchurch Hospital provides complex specialist care and is the South Island’s major trauma centre.

Nationally, falls were the most frequently reported serious adverse events, followed by severe pressure injuries. Delays in referrals, follow-up, diagnosis or treatment were another common category.

Sullivan said work underway included strengthening workforce planning, safe staffing escalation and resource allocation.

“Work underway includes improving referral and follow-up processes, reviewing waitlists, strengthening falls and pressure injury prevention, and rolling out tools such as electronic observations and early warning scores. This is about helping staff spot risks earlier and act sooner.”

The report follows a July 2025 directive from the Office of the Ombudsman for Health NZ to develop regular public reporting on serious adverse events.

Its scope excludes mental health, addiction and intellectual disability services, public health and commissioned services, as well as incidents involving moderate or minor harm and near misses.

Health NZ said it was committed to publishing the report annually.