CAMPANELLA, MR C.J.

504 The Hon. SANDRA KANCK (20 September 2006). Has the Royal Adelaide Hospital conducted a Root Cause Analysis inquiry in line with best practice quality control concerning the death of Cosmo Joseph Campanella on 12 December 2002?

The Hon. G.E. GAGO (Minister for Environment and Conservation, Minister for Mental Health and Substance Abuse, Minister Assisting the Minister for Health): The Minister for Health has advised that:

A root cause analysis was not conducted into the death of Mr Cosmo Campanella, as the structure approach for root cause analysis was not in place at that time.

When safety and quality issues were brought to light in the early stages of the Coronial Investigation, a working party was formed in 2004 to review tracheostomy management at the Royal Adelaide Hospital. A number of significant improvements have since been made.