Chemotherapy Treatment Error

The Hon. J.J. SNELLING (Playford—Minister for Health, Minister for the Arts, Minister for Health Industries) (15:14): I seek leave to make a ministerial statement.

Leave granted.

The Hon. J.J. SNELLING: Over a period of six months, from 2014 to 2015, five patients at the Royal Adelaide Hospital and five patients at the Flinders Medical Centre were given an incorrect dosage of the chemotherapy drug cytarabine, receiving one dose a day instead of two during their treatment. As a result of this, in August last year, I commissioned an independent panel of experts, led by Professor Villis Marshall, Chair of the Australian Commission on Safety and Quality in Health Care, to review the events and decisions that led to the underdosing.

Following an extensive review, the panel found that the underdosing was caused by a series of significant clinical governance failures at the Royal Adelaide Hospital haematology unit. Among them was the failure to follow routine clinical processes and procedures, and not advising patients that the chemotherapy protocol was a non-standard protocol that required approval from the relevant committee and informed patient consent. In addition, the panel found that certain clinical staff did not comply with SA Health incident management and open disclosure policies, including not conducting timely and appropriate open disclosure with patients.

The panel made four recommendations, all of which have been accepted by SA Health. Following this review's recommendations, I can now advise the house that eight clinicians have been referred to the Australian Health Practitioner Regulation Agency. AHPRA is responsible for investigating concerns about health practitioners' conduct and practice on behalf of national boards, including the Medical Board of Australia.

I am advised that AHPRA is currently assessing this referral and the clinicians' conduct for investigation, and SA Health will make all relevant material available to that investigation. Following any investigation, AHPRA will report the outcomes to the Medical Board of Australia. As in any investigation of this type, if adverse conduct is discovered, the Medical Board of Australia will consider what action is appropriate. In the case of adverse conduct, a range of penalties are available to the board, including imposing conditions on a clinician's registration to limit their practice, or taking action that could result in suspension or loss of registration.

Taking into account the findings of the Marshall review, SA Health is also conducting a further internal investigation into the issue. This investigation is focusing on all relevant material and documents to provide a comprehensive insight into this complex and detailed case. Again, as in any similar investigation, should adverse conduct be discovered as part of this investigation, a range of actions, including disciplinary measures, would be available to the chief executive.

Last week, I met with Mr Andrew Knox, one of the affected patients, who expressed justifiable concern about a lack of support from our health services following the dosage error. I share Mr Knox's anger. I can advise the house that each of the affected patients has now been offered a care coordinator to act as one point of contact to ensure their needs are being met, including health, emotional, social or practical support. I can also confirm that their clinical specialists will continue to provide clinical care and treatment. Patients will also be provided with regular updates on progress made against the recommendations of the expert panel.

As Professor Marshall's review stated, this has been a serious failure in clinical governance. Patients need to feel safe when they are being treated in our health system, and I am angry and frustrated by the fact that systems put in place to protect patients have not been followed. The referral of clinicians to AHPRA is a significant and serious outcome, and this investigation must be allowed to run its course.

While in principle I support a parliamentary inquiry into this matter, given its gravity, I ask members in the other place to defer such an inquiry, in particular, until AHPRA has concluded its investigation. It is important that ongoing investigations, including any disciplinary proceedings, are not compromised.

Ms Chapman: Where is Professor Marshall's report?

The Hon. J.J. Snelling: It's on the website.

The Hon. P. Caica interjecting:

The SPEAKER: The member for Colton is the first person called to order for the year—

Members interjecting:

The SPEAKER: —provoked though he was.