Juliette McAleer is a former public sector leader and PhD candidate living with disability arising from the physical and psychosocial consequences of preventable healthcare harm. Based in regional Queensland, Australia, Juliette writes from her lived perspective of harm and its aftermath, focusing on post-harm responses and how they shape safety, trust, and the possibility of relational repair. Contact: juliettemcaleer@yahoo.com.au
In Part 1, I described what healthcare harm looks like from the inside. I shared my lived experience of harm, the aftermath, and described some of the compounded harms that follow when systems respond to harm with procedure rather than relationship. Here, I want to explore what a different response might look like, and what it will take to build a more human-centred one.
Restorative practices enter this space with genuine promise, as a relational framework that centres healing alongside learning (Wailling et al., 2025). In Aotearoa New Zealand, a restorative approach to surgical mesh harm addressed most participants’ procedural and psychological needs and uncovered information that institutional investigations alone had missed (Wailling et al., 2020). In Queensland, Australia, embedding restorative just culture into clinical incident responses in mental health settings reduced staff fear and blame and produced stronger safety recommendations (Turner et al., 2022), while an independently evaluated trial at The Prince Charles Hospital demonstrated the value of restorative approaches in addressing interpersonal harms in secure mental health and community settings (Beere, 2022). I want to acknowledge the pioneering scholars and practitioners whose sustained work made these developments possible. Yet outside of a handful of groundbreaking initiatives, Australia’s healthcare system’s standard responses to harm remain far from restorative. Open disclosure, the closest thing most harmed patients will encounter in most jurisdictions, aspires to honest communication and acknowledgment, but in practice its relational intent is often subordinated to compliance and risk management, fostering what has been described as a “tick-box approach” that can detract from genuine human connection (Mordaunt, 2026). There are however, signs of progress already appearing in this space: including in New South Wales, where a draft incident management policy currently out for consultation introduces restorative communication and restorative just learning as core principles governing the state’s response to healthcare harm (NSW Health, 2026).
That said, scholars warn that compounded harm can still emerge when institutional goals eclipse those of the affected community (Wailling et al., 2025). Christie (1977), described how systems steal conflicts from those to whom they belong. Conflicts in this context refer to the relational dynamics of the harm itself—who defines what happened, who decides what happens next, and whose needs shape the response. Wood & Suzuki (2020), traced how institutionalised restorative justice has, in some settings, reproduced exactly this—institutional interests overriding those of the people the process was designed to serve. The pre‑defined categories embedded in healthcare complaints, governance processes and medicolegal assessments share a common logic. They determine in advance what counts as harm, who defines it, and what outcomes are possible. Without deliberate attention to whose voices are centred, restorative responses in healthcare risk unconsciously replicating the very harms they set out to address—a risk already the subject of caution across restorative initiatives in five countries (Wailling et al., 2025).
If restorative responses in healthcare are to avoid reproducing institutional power dynamics, their design must be shaped by the people whose experience of harm reveals what no institutional perspective alone can. The aspiration to involve lived expertise in healthcare is not new. The Declaration of Alma-Ata (World Health Organisation, 1978) affirmed the right of people to participate in healthcare planning almost fifty years ago. In Australia, the National Safety and Quality Health Service Standards has required health services to partner with consumers since 2011, and the second edition strengthened this to explicitly require consumers as partners in organisational design and governance (ACSQHC, 2017). Despite this, a national survey found that most consumer involvement has concentrated on operational or “bolt-on” activities, such as advising on patient-facing information, rather than genuine integration into system design (Farmer et al., 2018). This demonstrable gap between policy aspiration and lived reality is not unique to Australia and remains globally significant (Ocloo et al., 2021).
There is a well-documented tendency for institutions to involve patient representatives at the lowest levels of participation, in ways that amount to consultation rather than partnership (Ocloo & Matthews, 2016). In mental health, lived experience engagement has deeper roots than anywhere else in healthcare, built on decades of consumer activism and peer support. Yet even there, a recent systematic review found that people with lived experience were involved in co-design processes but almost never as decision makers (Veldmeijer et al., 2023). In some Australian states, lived experts in mental health are now required to hold formal qualifications before they can contribute—a requirement that risks filtering the very expertise it claims to value through pre-defined institutional frameworks before it can even enter the room. If this is the state of play in the mental health disciplines with decades of infrastructure for involvement, it seems the rest of healthcare has some formidable challenges ahead including (or perhaps especially) for those wishing to introduce restorative responses here.
Restorative practices privilege voluntariness. Not everyone who has been harmed will want to access a restorative response or be part of this knowledge-building and design work, and that choice must always be respected. But for those who do, participation cannot be left to chance. A harmed person arrives carrying layers of compounded harm (Wailling et al., 2022). They may be experiencing financial precarity, may be cognitively affected, and are almost certainly still dependent on the system that harmed them. Those they are asked to work alongside typically arrive with institutional affiliations, professional credentials, resources and access the harmed person may not have. People still entangled with the system that harmed them may need thoughtful invitation, sustained support, and real assurances of safety before they can bring what they know. Equity in this context requires deliberate work by those holding power to redistribute it. Those who invite harmed people in must be prepared to listen with humility when what they hear is confronting, and to reckon with the reality that the gap between listening and truly hearing is wider than most engagement processes account for (Walklate, 2025).
The space between patients and healers doesn’t have to remain a site of managed threat. With consciousness and will, restorative approaches can be incorporated in ways that don’t reproduce the dynamics they seek to transform. Nobody in the health system set out to harm me, and the staff involved carry their own injuries from what happened. I do not want retribution. What I want is to be taken seriously as someone whose insight might help shape a better response for all of us. “First, do no further harm” belongs at the centre of restorative design in healthcare, as a design imperative that demands we ask whether the response itself risks becoming another site of injury. (Freyd, 2018), calls the antidote to institutional betrayal institutional courage: and defines it as an institution’s commitment to seek the truth and engage in moral action, despite short‑term risk and cost. Restorative design in healthcare demands exactly this. It means finding us, supporting us, and staying when what we say is confronting.
References
- ACSQHC. (2017). National Safety and Quality Health Service Standards, Second Edition. Australian Commission on Safety and Quality in Health Care.
- Beere, D. (2022). A mixed methods evaluation of the implementation of Restorative Practice in mental health services at The Prince Charles Hospital. Queensland Mental Health Commission. https://www.qmhc.qld.gov.au/sites/default/files/downloads/a_mixed_methods_evaluation_of_the_implementation_of_restorative_practice_in_mental_health_services_at_the_prince_charles_hospital_-_full_report.pdf
- Christie, N. (1977). Conflicts as Property. British Journal of Criminology, 17(1), 1–15.
- Farmer, J., Bigby, C., Davis, H., Carlisle, K., Kenny, A., & Huysmans, R. (2018). The state of health services partnering with consumers: Evidence from an online survey of Australian health services. BMC Health Services Research, 18(1), 628. https://doi.org/10.1186/s12913-018-3433-y
- Freyd, J. J. (2018, January 11). When sexual assault victims speak out, their institutions often betray them. The Conversation. https://doi.org/https://doi.org/10.64628/AAI.wx7sq7qa3
- Mordaunt, D. A. (2026). Balancing rights and governance: Comparative analysis of open disclosure frameworks in Australia and New Zealand. New Zealand Medical Journal.
- NSW Health. (2026, February). Incident Management [Health Policy Directive Draft D26/1984]. NSW Government. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0019/1036405/Consultation-draft-Incident-Management-Policy.pdf
- Ocloo, J., Garfield, S., Franklin, B. D., & Dawson, S. (2021). Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: A systematic review of reviews. Health Research Policy and Systems, 19(1), 8. https://doi.org/10.1186/s12961-020-00644-3
- Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment: Progressing patient and public involvement in healthcare improvement. BMJ Quality & Safety, 25(8), 626–632. https://doi.org/10.1136/bmjqs-2015-004839
- Turner, K., Sveticic, J., Grice, D., Welch, M., King, C., Panther, J., Strivens, C., Whitfield, B., Norman, G., Almeida-Crasto, A., Darch, T., Stapelberg, N. J. C., & Dekker, S. (2022). Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses. Journal of Hospital Administration, 11(2), 8. https://doi.org/10.5430/jha.v11n2p8
- Veldmeijer, L., Terlouw, G., Van Os, J., Van Dijk, O., Van ’T Veer, J., & Boonstra, N. (2023). The Involvement of Service Users and People With Lived Experience in Mental Health Care Innovation Through Design: Systematic Review. JMIR Mental Health, 10, e46590. https://doi.org/10.2196/46590
- Wailling, J., Cameron, G., Stolarek, I., Turner, S., Bleakley, B., O’Connor, N., Harwood, C., Power, M., Turner, K., Kooijman, A., Oelke, N. D., Gustafson, D., Robson, R., Anderson Wallace, M., Drennan, G., Hughes, J., O’Hara, J. K., Swanepoel, F., & LeMaster, C. H. (2025). Restorative initiatives: Emerging insights from design, implementation and collaboration in five countries. Frontiers in Health Services, 5, 1472738. https://doi.org/10.3389/frhs.2025.1472738
- Wailling, J., Kooijman, A., Hughes, J., & O’Hara, J. K. (2022). Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expectations, 25(4), 1192–1199. https://doi.org/10.1111/hex.13478
- Wailling, J., Wilkinson, J., & Marshall, C. (2020). Healing after harm: An evaluation of a restorative approach for addressing harm from surgical mesh. Kia ora te tangata: He arotakenga i te whakahaumanu.
- Walklate, S. (2025). Victim-Survivor Stories of Restorative Justice: Why Should They Matter? The International Journal of Restorative Justice, 8(3), 395–414. https://doi.org/10.1163/25890905-00803002
- Wood, W. R., & Suzuki, M. (2020). Are Conflicts Property? Re-Examining the Ownership of Conflict in Restorative Justice. Social & Legal Studies, 29(6), 903–924. https://doi.org/10.1177/0964663920911166World Health Organisation. (1978). Declaration of Alma-Ata: International Conference on Primary Health Care, Alma-Ata. https://www.who.int/publications/i/item/declaration-of-alma-ata
