House of Assembly Fifty-Third Parliament, Second Session (53-2) 53 2 Parliament of South Australia House of Assembly published Ministerial Statement Ministerial Statement Chemotherapy Treatment Error Chemotherapy Treatment Error The Hon. J.J. SNELLING House of Assembly Playford Minister for Health Minister for the Arts Minister for Health Industries The Hon. J.J. SNELLING (Playford—Minister for Health, Minister for the Arts, Minister for Health Industries) (14:02): I seek leave to make a ministerial statement. Leave granted. The Hon. J.J. SNELLING House of Assembly The Hon. J.J. SNELLING: As the house is aware, 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 a chemotherapy drug, Cytarabine. In August 2015, 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 lead 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. Following the review's report, eight clinicians were referred to the Australian Health Practitioner Regulation Agency (AHPRA), which is responsible for investigating concerns about health practitioners' conduct and practice on behalf of national boards, including the Medical Board of Australia. I met with AHPRA yesterday afternoon to receive an update on its investigation. AHPRA told me they had finalised nine matters concerning four medical practitioners and five pharmacists. Of those matters, they advised that eight investigations were finalised, with no further action, and one matter had resulted in a caution. AHPRA also advised me that three of the more complex matters are still under investigation and may result in regulatory action. SA Health has this week also provided me with an update on its internal disciplinary investigation. I am advised that yesterday two staff were stood down by SA Health, pending the outcome of SA Health's disciplinary process. Another staff member has been directed to undertake a formal performance management process. One staff member is still in the disciplinary process. No adverse findings have been made against seven staff members who are subject to the investigation. As I have said before, this has been a serious failure in clinical governance. Patients must feel safe when being treated in our hospitals. This government has taken this matter very seriously and, through our referral to AHPRA and SA Health's investigation, significant action has been taken against those responsible. I understand, however, that the length of time it has taken to get to this point in the industrial process is very frustrating and distressing for victims and their families. While I share this frustration, SA Health has been bound by the relevant industrial instruments and laws. I have asked for advice on whether the current employment arrangements for senior medical staff in the public sector are appropriate in terms of protecting our patients. At the executive level, our senior bureaucrats are employed under contracts with specific clauses that provide appropriate industrial protections for the employee while allowing the employer to take swift action in terminating employment should the employer consider there are grounds to do so. In contrast, senior doctors, who are on executive level salaries, are subject to enterprise bargaining agreements. These agreements necessitate very specific processes to be followed before employment can be terminated. While the process usually provides the same end result, had the employee been a senior executive, the process is much longer. This can cause significant pain and angst for patients and families involved, particularly where a clear breach has occurred. While all workers should be provided procedural fairness regardless of their pay—a longstanding principle of administrative law—the government, and indeed this parliament, needs to consider where there is a need to reform these arrangements to allow decisive action in cases where patient safety may be compromised. This in no way should be seen as an attack on our hardworking doctors, the vast majority of whom always do the right thing and work tirelessly to provide the best care to our patients. This is as much about protecting the integrity of their profession as it is about protecting their patients and ensuring the public continues to hold their profession in the highest esteem. In the case of the incorrect dosage of chemotherapy, I made a commitment to victims and their families that I would make public any outcomes of the investigations. I will continue to do so. While yesterday's action cannot change the events of the past, I hope it brings some solace to those victims and their families.