An external review has been ordered after three "unexpected deaths" this year at a Christchurch hospital psychiatric unit.
The Canterbury District Health Board (CDHB) said the tragic deaths all occurred at the Adult Inpatient Service at the city's Hillmorton Hospital.
CDHB chief of psychiatry, Associate Professor Phil Brindedsaid three deaths within a few weeks, including two within 48 hours, was "unprecedented" for the service.
"It is a reality of mental health services that occasionally we do have deaths. But inpatient deaths are very rare. To have this number over this period of time is unprecedented for us. We have never experienced anything like this before."
None of the three deaths are believed to have a suspicious element.
The CDHB is trying to reassure people the service is still safe, and interim measures to improve safety are already being looked at.
"Commissioning an external review does not mean that these patients did not receive adequate care," said Dr Brinded.
"We are however very concerned about their deaths and the short space of time in which they occurred."
"We want to take a very close look at the circumstances surrounding them and whether anything further could have been done to prevent them."
A senior psychiatrist, Professor Graham Mellsop, has been commissioned to lead the review panel.
Other members of the panel are yet to be assigned, but will include a senior nurse.
The reviews will cover admission, assessment and treatment of people entering acute inpatient services.
The families of the three dead had been told of the reviews and were being offered support.
"We have made it very clear to staff and families that this review is about getting an overall picture of the way the service functions, and finding anything that can be done to improve patient safety," Dr Brinded said.
"This move is not a reflection on staff who work very hard caring for their patients."
The timeframe for the completion of the review is yet to be established.
In the meantime, the CDHB was looking for any obvious changes that could be made to improve patient safety, Dr Brinded said.
"I would like to reassure the people who use the service and their families, that we are working to provide the best standard of care possible."
"It is still the very best place to come for Canterbury people who are acutely mentally unwell and require hospital care."
The three deaths will also be individually reviewed by a coroner.
