An evaluation of a restorative process to address harm from surgical mesh

The Ministry of Health has published an evaluation of a restorative process designed to listen, understand, and address the harms New Zealanders suffered as result of surgical mesh.

The evaluation report, ‘Healing after Harm: An evaluation of a restorative approach for addressing harm from surgical mesh, Kia ora te tangata: He arotakenga i te whakahaumanu’ was commissioned from a team of researchers at Victoria University’s Te Ngāpara Centre for Restorative Practice who evaluated information provided by 230 people who took part in the restorative process.

The restorative process was co-designed by the Ministry of Health, advocacy group Mesh Down Under and Te Ngāpara Centre for Restorative Practice, Te Herenga Waka Victoria University of Wellington and delivered in three phases from July to December 2019 - Listening and Understanding, Planning and Acting, and Reporting and Evaluating. It’s thought to be the first time a restorative approach has been applied to a national healthcare issue in New Zealand or around the world.

Surgical mesh is a medical device used when repairing weakened structures with the aim of providing additional support. While some people who have mesh inserted experience no harm, many do, including people who have undergone pelvic floor, hernia or other procedures. Some people experience harm immediately after their operation, while for others, harm is experienced years later.

Through the restorative process, more than 600 mesh-harmed people shared their stories of mesh-harm, bringing to light the severity of physical and psychosocial harms. Many people described these as ‘life changing’. For many, harm was compounded by the professional and agency responses that followed, resulting in loss of trust in healthcare providers and public institutions.

The evaluation report finds that mesh-harmed people who shared their stories were able to effectively communicate the massive extent of harm and injury after surgical mesh procedures, which helped the Ministry of Health, ACC and Health and Disability Commission in their work with other agencies to minimise further harm from surgical mesh.

Most people who took part in the evaluation said the experience made them feel validated and provided them the opportunity to communicate their experience, preserve dignity. However, many evaluation participants were largely unaware of progress on the 19 actions that resulted from the Planning and Acting phase of the project and were unsure if their needs would be met in the future.

Of the 19 actions, six have been completed, nine have been completed and require ongoing attention and four are in progress.

The Ministry has established a collaborative approach to harm from surgical mesh and set national standards. The Ministry is working on establishing specialist service centres for mesh complications, developing education resources for health professionals and consumers, and will soon release a New Zealand Credentialing Framework, which will be used in the future as the basis of a process to credential surgeons carrying out pelvic floor procedures, to give confidence that they are appropriately qualified and skilled to do so. This will replace the current use of the Australian credentialing framework.   

ACC also committed to reassess previously declined injury claims for mesh harmed people, which is still open. Anyone who has had a surgical mesh claim declined prior to 28 October 2020 can have their claim reassessed (more information at ACC’s website).

The Ministry of Health has provided a summary of progress on its website (Hearing and Responding to the Stories of Survivors of Surgical Mesh: Updates).

“The release of this evaluation completes the three phases of the project – a restorative approach to surgical mesh harm. However, it does not signal the end of the restorative process which aims to restore wellbeing, relationships and trust in so far as this is possible. Whilst the evaluation found that some degree of trust was regained in the Listening and Understanding phase - it also told us that we need to deliver on our promised actions in order to maintain that trust. The Ministry is committed to supporting those affected by surgical mesh, and to use the learnings of this experience to prevent future harm,” said Robyn Carey, the Ministry of Health’s Chief Medical Officer. “We have updated the summary of action taken in response to the process, on our website.”  

“We are grateful to everyone who made the decision to share their story with us and to health organisations that took part in the process. As one participant said, ‘despite everything that people had lost, people came along to talk to us in a very clear-minded and often fair-minded way, and for everything that had been destroyed, people’s humanity was still intact’. We are grateful to our co-design partners - advocacy group Mesh Down Under and Victoria University - for their work to create a space that most people found to be safe to share their story,” she said.

Background

About the restorative process

• The Ministry of Health, Mesh Down Under and Victoria University designed the restorative process based on an independent analysis of a public survey from December 2018 to January 2019. People were provided with different options so that they could share their story in a way they had indicated would be meaningful.
• The restorative process was conceptualised in terms of the individuals and relationships affected and helped the Ministry of Health to listen and understand the lived experiences of New Zealanders affected by surgical mesh harm to inform reparative action and prevent future harm. It’s thought to be the first time a restorative approach has been applied to a national healthcare issue in New Zealand or around the world.
• A restorative approach to surgical mesh harm was delivered in three phases from July to December 2019. The phases were: (i) Listening and Understanding, (ii) Planning and Acting, and (iii) Reporting and Evaluating. A description of each phase can be found in the project report Hearing and Responding to the Stories of Survivors of Surgical Mesh.
• Experienced restorative practitioners supported participants during each phase of the project and the approach was adapted in response to the emergent needs of individuals, groups, and responsible parties.
• The ‘Listening and Understanding’ phase of the restorative process invited mesh injured New Zealanders, and family and whānau, to share their lived experience of surgical mesh harm with the people responsible for repair and prevention. Over 600 women and men shared their experiences in 32 Listening Circles, facilitated meetings and a Story Database.  Additional stories were provided by health professionals.
• The ‘Planning and Acting’ phase brought people from the organisations identified as responsible parties to clarify responsibility for the harms that had occurred and resolve together how best to promote repair and bring about positive changes for all involved. Eventually 19 actions were agreed and documented in the final report. Responsibility for ongoing governance and delivery sits with the Mesh Round Table which has been operating since 2017.
• The Ministry of Health released the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019. The report details the severity of the physical and psychosocial harms that New Zealanders suffered as a result of surgical mesh use. Many people described these as ‘life changing’. This report describes how harm was compounded by the professional and agency responses that followed, and the resulting loss of trust in healthcare providers and public institutions. The report includes the reparative and preventative actions agreed within the Planning and Acting phase.

Evaluation findings

The descriptive evaluation was co-designed and aimed to ascertain whether good practice was demonstrated by the project delivery team; to understand people’s experiences of the process; to find out whether the project objectives were met; and to assess whether the approach could be used elsewhere in the health and disability sector.

The evaluation concluded that:

• The restorative process met people’s needs during the Listening and Understanding phase of the project. Most participants expressed that they experienced respectful communication, the preservation of their dignity, validation of their experience. Restorative Circles were particularly effective.
• The massive extent of the harm caused by surgical mesh was powerfully communicated, and the responsible parties were inspired to collaborate and undertake actions for repair and prevention.
• After the Planning and Acting phase had ended the majority of consumers were unaware of the actions taken by the Ministry of Health and other responsible parties.
• Restorative approaches are potentially transferable to other health contexts if the critical success factors are met (page 24).
• Healing after harm is possible when approached within a relational framework and this should be embedded alongside existing regulatory structures, policies, and procedural responses. A collaborative approach to design, which distributes leadership amongst communities, advocates, and agencies, will promote success and build trust.
• Restorative approaches resonate with the relational approach of Te ao Māori and have more to offer Aotearoa New Zealand than traditional investigative methods. 
• Ongoing testing and refining of restorative approaches in different contexts will be important to understand what works for whom, in what contexts and how.

Methods 

• Ethics approval for the research was granted by the Victoria University Human Ethics Committee.
• The researchers included Jo Wailling RN, Senior Research Fellow, Te Ngāpara Centre for Restorative Practice who led the co-design, research, and evaluation of the surgical mesh project from its inception; The previous Diana Unwin Chair in Restorative Justice, Emeritus Professor Chris Marshall who was the academic supervisor for the project; and Jill Wilkinson RN, in her previous role as a Research Fellow at Te Ngāpara Centre for Restorative Practice.
• The researchers evaluated the process and immediate impacts of the restorative approach within a health assessment framework. They used surveys and interviews to collect information from 230 consumers and responsible parties about their experiences. The questions researchers asked were informed by an analysis of what people said they hoped the project would achieve during the registration process.
• The COVID-19 pandemic delayed data collection, which took place during May - July 2020. The report was submitted to the Ministry of Health in December 2020.
• COVID-19 also caused delays to the reviewing, and publishing of the report as government, and the health sector, focused on responding to the pandemic. The report has now been finalised and is being shared with those who took part in the restorative process and with the wider public.

ACC

• ACC committed to reassess previously declined injury claims for mesh harmed people. This reassessment opportunity is still available and open to anyone who has had a surgical mesh claim declined prior to 28 October 2020. More information is on ACC’s website.