15 Nov 2017

Culture Clubbed | The Advertiser

CULTURE CLUBBED | PENNY DEBELLE

SA HEALTH has been condemned for its “culture of blame, fear of retribution and inertia” in a parliamentary report that also highlighted the role of the media in uncovering the chemotherapy underdosing bungle at two major hospitals. In the most critical report so far on the impact on patients, the Report of the Select Committee on Chemotherapy Dosing Errors criticised SA Health
for failing to investigate properly and for waiting until the scandal became public.

“It should not have been necessary for the matter to be raised in the media for such an investigation and action to occur,” the committee found. The committee, chaired by Liberal MLC Andrew McLachlan, was very concerned by the decade-long lack of action by SA Health to numerous reports and reviews that identified cultural problems in the department and which contributed to
the mistake that saw 10 seriously ill leukaemia patients underdosed during chemotherapy “The committee is of the opinion the error, and the response to the error, were unequivocal evidence of systemic cultural problems within SA Health,” the report found.

One of its recommendations was that SA Health be independently audited each year to ensure it complied with policies and procedures, and that training be given to all staff including the most senior doctors.

“The chemotherapy underdosing highlighted a disregard for contemporary health management practices within FMC, RAH and SA Pathology,” it found.

The RAH – which last week received a letter of complaint from a seriously ill myeloma patient whose signs of relapse were missed – was again singled out for failures of clinical governance. The committee quoted evidence that “the RAH’s august opinion of itself is not matched by its governance”.

The select committee, set up in March 2016, took evidence from patients, including harrowing testimony from Bronte Higham, who died a few weeks later but whose plea for compensation helped reverse the previous “painful and distressing experiences” patients had with SA Health and State Government insurer SAICORP.

Committee members were moved by the extent of the psychological and physical impact on the patients and families. This included the time taken to tell patients, including one man who was only told on his third visit after the mistake was discovered, and the lack of support. “This treatment error has had an adverse impact on their lives and the lives of their families,” the report said.

The unequivocal evidence of cultural problems the committee uncovered ran to inaccurate public statements made by the Minister of Health and the SA Health chief executive. In August
2015, when The Advertiser broke the story of the chemotherapy bungle, the then minister Jack Snelling said no patient had died. It emerged later that one patient, Johanna Pinxteren, had relapsed and died two months earlier.

“The result is an unhealthy hierarchical orgganisational environment within SA Health resulting in a culture of blame, fear of retribution and inertia,” the report said.

Patient Andrew Knox, who is recovering from a serious relapse, said the report highlighted that many longstanding suggestions had been ignored, with elements in SA Health being “laws unto themselves”.

Health Minister Peter Malinauskas said he would consider the report’s findings. “What happened to these patients was unacceptable and represented a clear failing in the standards we expect,” he said. “There have been numerous investigations into this incident. All the subsequent recommendations have been accepted and have either been implemented or are being progressed.”