The New Zealand Health Quality and Safety Commission identifies that Health Care is complex and that improving quality and safety in the 21st century is challenging. At the West Coast District Health Board (West Coast DHB) our commitment to patient focused continuous quality improvement supports our aim of ‘zero-harm’. All serious adverse events are reviewed through a formal process in order to analyse our existing health practices and systems. The purpose of reviewing these is to provide sufficient feedback to patients and their families/whānau so they can gain insight into any contributing factors and causes of the event and understand how the DHB intends to make our systems safer.