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15 Nov 2017

Select Committee on Chemotherapy Dosing Errors Final Report

The Hon. A.L. McLACHLAN (16:45): I move:

That the report of the select committee be noted.

The select committee of the Legislative Council, which was established to inquire into and report on the chemotherapy dosing errors at the Royal Adelaide Hospital and the Flinders Medical Centre in 2014 and 2015, has completed its report. As members would be aware, it was tabled yesterday.

I remind honourable members that the select committee, in addition to being tasked by the chamber to inquire into the chemotherapy dosing errors, was also specifically asked to focus on the extent to which the culture, governance and management of the relevant hospital departments and their associated statewide services contributed to the risk of errors; SA Health’s and government’s response to the errors, including the inquiry led by Professor Marshall; the suitability of SA Health’s incident management processes in terms of patient safety, transparency and institutional risk management; and the impact of risk management, including the management of legal risks, on the support of victims and the transparency of the health system, in particular the use of confidential agreements.

The committee was made up of myself as Chair, the Hon. Mr Darley, the Hon. Mr Dawkins and the Hon. Ms Gago. I would like to thank all members of the committee for their support to me as Chair and for their diligent work and commitment on the committee. I also wish to thank the secretary, Mr Anthony Beasley, and the research officer, Ms Carmel Young.

After considering all of the evidence before it, the committee made 19 findings and 12 recommendations. The committee met on 14 occasions to hear evidence. We took evidence from a total of 31 witnesses. Hearings began on 31 May 2016.

I am aware that other members on the committee are going to speak to the report. It is my intention to revisit those particular issues in the report that were of special interest to myself and to provide an overview of our findings.

Between July 2014 and January 2015, 10 patients with acute myeloid leukaemia—five at the Royal Adelaide Hospital and five at the Flinders Medical Centre—received an incorrect daily dose of their treatment, instead of the correct dose of twice daily.

The Central Adelaide Local Health Network and its hospital, the Royal Adelaide Hospital, had a protocol which contained the incorrect dosage. That protocol was adopted by the Flinders Medical Centre as a new protocol without checking its veracity independently, and thus other patients were treated incorrectly.

Throughout the inquiry, patients and their families provided evidence of their painful and distressing experiences in dealing with SA Health and the South Australian insurance corporation. Committee members were deeply moved to hear of the extent of the psychological and physical impacts of the chemotherapy underdosing, not only on the patients themselves but also their families and loved ones. The treatment error has had an adverse impact on their lives and lives of their families.

The evidence of the patients and their families clearly demonstrates the absence of a coordinated patient-centred approach by SA Health to their physical and psychological needs. I thank them and their families for attending committee meetings, giving evidence and reliving painful memories and circumstances of their treatment.

The committee could not have done its work without their courage. Patients were left in a position of uncertainty, never knowing the potential impact of the chemotherapy underdosing on the chances of surviving their illness. The realisation that the error also prevented the opportunity to access further trials and studies was a constant source of anguish for the patients and their families.

The committee found that the patients who received an incorrect treatment were adversely affected by unacceptable standards of governance within SA Health. This was evident in the poor management of the protocols by certain clinicians; the decision to make changes to the protocol without the prior consent or knowledge of the patients; the failure to report the incidents at the highest level of the Safety Learning System, as required by SA Health’s policies and procedures; a reluctant and inconsistent approach to open disclosure; and the absence of dedicated care coordinators from the time the error was identified. Patients gave evidence to the committee on the stress they felt from their treatment by SA Health and the government insurer. As one patient stated:

I am a dead man walking. I don’t know when I am going to fall of the perch…so I don’t want my family to go for years asking for compensation. The victims and the families deserve compensation for this, because it has been just one big stuff up. Families don’t deserve to have to go through years and years of waiting for compensation, and fighting. It has been 18 months of hell already. Unless it happens to you and your family, you don’t realise how stressful it is.

One patient’s wife also highlighted the stress on family members advising the committee:

We have just had enough. We have got enough stress in our lives. We want the time we have to be quality time and not have all this stuff going on.

I want to highlight one piece of correspondence that was sent by SA Health to the patients. The patients were highly distressed to receive a letter, dated 27 May, from Professor Moyes, the former CEO of the Southern Adelaide Local Health Network. The letter, which was sent four months after the open disclosure process began, provided an apology for the error and advised that their haematologist would liaise with them on future treatment. Patients were extremely critical of the generic nature of the letter, the timing and the content—driven, it appears, by the need to limit liability and the presumption that the victims had actually received some support. One patient told the inquiry that the letter was impersonal and lacked any understanding of what the patient had been through:

It was an awful, awful letter. She didn’t have any clue who I was, what I had been through, what had happened. I could have died the week before. Just a letter, no contact, nothing.

Professor Marshall, who undertook a review on behalf of SA Health, when speaking about the letter, said:

…that certainly was one that was lacking in empathy…It was much more likely to be considered an offensive letter.

The committee formed the opinion that the error and the response to the error were unequivocal evidence of a systemic cultural problem within SA Health. The then SA Health chief executive, Mr Swan, told the committee in respect to the email in relation to the chemotherapy protocol (and for the benefit of members, the incorrect protocol was distributed by email) that its content was:

…manifestly inadequate in its context, clarity and course of action that should have been taken.

The lack of response to the email by senior clinicians further demonstrated noncompliance with SA Health policies and guidelines. This is the email that alerted the correction to the error:

Importantly, senior clinicians of the Royal Adelaide Hospital who received this email and were aware of the error in dosing should have identified its shortcomings, complied with SA Health policies and guidelines, and taken immediate remedial action. I find this action deplorable.

The Marshall review was of the opinion that this lack of noncompliance was not a one-off occurrence at the Royal Adelaide Hospital. I quote from the review:

The panel was informed that medical staff at the RAH did not frequently lodge incidents in the SLS and were slow to respond, if at all, when asked to review an incident that had been lodged by someone else.

The committee was very concerned by the lack of action within SA Health with regard to numerous commission reports and reviews, spanning a 10-year period that had consistently identified ongoing systemic cultural deficiencies.

The committee determined that the findings of one particular review, the Brook and Phelps review, are fundamental to cultural change that must take place within SA Health. However, the committee is very concerned by the poor progress against the action plan set out by Professors Brook and Phelps. The committee believes that SA Health must pursue excellence in all its endeavours to ensure the best possible practice in clinical governance.

The committee acknowledges that work is being undertaken in relation to improved safety incident reporting, and work was being done during the course of the time the committee was sitting. Nevertheless, more work is required in relation to safety and quality within SA Health, and which should be underpinned by a whole-of-department commitment.

It is important for honourable members to note that high staff turnover of senior management and key clinical leadership positions did have a significant impact on SA Health’s capabilities. The staff turnover had a negative impact on morale, the ability to make timely decisions and to implement, report and review recommendations. The result was an unhealthy hierarchy organisational environment within SA Health, resulting in a culture of blame, fear of retribution and inertia.

Having said that, I would like to acknowledge that much good work is undertaken in SA Health, and that the majority of those working in SA Health, particularly in the front line, do an excellent job, and this was acknowledged by the patients themselves. The committee recognises that the ability of staff to carry out their duties is often hampered by lack of action by senior leaders in responding to the findings and recommendations of previous reports and reviews.

There should have been robust structures for the handling of chemotherapy protocols in the first place. Projects were delayed or awaiting EPAS, the electronic system for managing health records. Putting off the inevitable or putting in alternate interim arrangements meant that there was a fertile ground for a mistake. A mistake occurred and there was a poor response, as I have indicated.

Future responses to errors must be patient-centric and done with compassion and understanding. Certainly the previous reviews and subsequent reviews acknowledged the same. As I said, work is being done to address these issues and against set time frames. In essence, it should not have taken media interest in the plight of the patients and their families to drive change in SA Health. SA Health should be pursuing excellence regardless, and this is going to be an ongoing cultural challenge for the leaders in SA Health.

I thank the patients for their courage in attending the committee hearings and giving evidence of painful circumstances for both them and their families. There was one disappointment: that there were a number, I think two at least, senior health officials who had moved, one overseas and one interstate. One provided a response in writing; the other refused to give evidence, except in camera.

The limits of the jurisdiction of a select committee are such that the committee decided to take evidence in camera, as for the benefit of its findings it needed the evidence. But, it was disappointing to all members of the committee that former senior health bureaucrats did not have the same courage as the patients themselves to respond to the legitimate inquiries of the select committee of this parliament. To me, as a parliamentarian, that was a great disappointment and a reflection of the poor culture that infected SA Health under their leadership. I am personally thankful that they are no longer with the health department.

To leave on a positive note, I think that during the time of the committee SA Health and its executives understood the challenge ahead of them, and acknowledged the pain and suffering they had caused these patients.

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