This report is the high-level public summary of this incident and the learnings identified from:
- an external review of services provided by Central Forensic Mental Health Services team (CFMHS);
- an internal review of the services provided by Stanford House by Whanganui Mental Health Services;
- and a services review by the Forensic Community Mental Health Team (FCMHT), CFMHS and Whanganui Mental Health Services more broadly, with a view to improving the quality and safety of care delivery and the experience of team members.