Select Committee on Chemotherapy Dosing Errors

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.

The Hon. G.E. GAGO (16:59): I rise to support the select committee's report into the chemotherapy underdosing of 10 patients at the Royal Adelaide Hospital and Flinders Medical Centre who were suffering with acute myeloid leukaemia. I would like to thank the other committee members: the Chairperson the Hon. Andrew McLachlan; the Hon. John Darley; the Hon. John Dawkins; our secretary Mr Anthony Beasley; and our research officer Ms Carmel Young. I support all 17 recommendations found in the report, and believe that the implementation of these, along with changes already made in response by the RAH and Flinders Medical Centre, will ensure that such a dreadful incident will be prevented from ever happening again.

The incorrect dose was given as a result of the introduction of a new chemotherapy treatment protocol by the Central Adelaide Local Health Network and the Royal Adelaide Hospital which contained an incorrect dose. To make a mistake of this magnitude is a terrible thing, but the issues that concerned the committee even more were what can only be described as the shocking mishandling and inaction by some senior clinicians and bureaucrats that followed. The committee heard from many of the patients involved and their families about how this had a devastating impact on their lives, and about the enormous pain and suffering it inflicted. I would like to thank and acknowledge the patients and their families who came in and shared their very painful stories with us for the courage they showed in doing that.

The committee found the underdosing occurred because of unacceptable governance practices within SA Health. Some of these practices included the mismanagement of the acute myeloid leukaemia protocols, the decision to make changes to protocols without the prior consent of patients, failure to follow SA policy and procedures relating to the reporting of incidents, and the uncoordinated approach to open disclosure of errors.

It was very clear to the committee that the patients involved and their families suffered substantial physical and psychological strain. Whilst giving evidence they recounted consistent examples of painful and distressing experiences with SA Health and SAICORP, detailing many examples of the paucity of coordinated care and lack of support. They felt their treatment after the error was discovered lacked respect, empathy and understanding.

Another area that demonstrated a lack of patient-centred care was the way compensation was handled by SA Health and SAicorp. Patients were advised by SAicorp to engage legal representation to make a claim. Small claim offers appear to have been made grudgingly, often under the threat of the offer being withdrawn altogether if they did not hurry up and accept, and often under the cloak of confidentiality clauses. As one patient said, 'I am a dead man walking…Families don't deserve to have to go through years and years of waiting for compensation, and fighting.'

The committee found it was completely unacceptable to require gravely ill people who had been subjected to a medical error to go to the additional time and expense of obtaining legal representation to enable them to make a claim for compensation. It found that at the time, SA Health and SAicorp lacked corporate policies and procedures that could provide an empathetic, patient-centred approach. It is pleasing to note that SA Health and SAicorp have since made the appropriate changes to their policies and procedures.

Another factor contributing to the mishandling of this incident was the lack of clear reporting lines, which resulted in inaccurate public statements. This in turn further distressed, angered and frustrated patients and their families. The lack of coordinated communication, delayed and scarce information, particularly up the chain of command, resulted in misinformation being given to the CEO of SA Health, the minister and the Premier, particularly in relation to seriousness of the incident, how the incident was being managed, and how it had occurred.

From the evidence that the committee received directly, as well as from findings from other investigations conducted by independent bodies or authorities, it was found that high staff turnover in senior clinical and management positions, plus the past decade of health services facing significant and rapid organisational change, impacted on morale generally. It also curtailed the ability to follow through and implement the recommendations made by a number of earlier reports to address a number of organisational concerns that had been previously identified. The committee found that in some parts of the organisation this had created an unhealthy hierarchical organisational environment, resulting in a culture of blame, fear of retribution and inertia.

A number of actions have been taken to investigate the underdosing incident, including this committee's report and other independent reviews. Earlier reviews have already caused important steps to be undertaken, and significant progress has been made.

The Marshall report made multiple recommendations, all of which have been accepted by SA Health and have either been completed or are currently being undertaken. An additional independent review into the use of the SLS system was commissioned as a result of the Marshall review. Conducted by the Australian Commission on Safety and Quality in Health Care, the review involved more than 600 staff members across CALHN, and the final report found a clear commitment to providing high-quality care within CALHN. The recommendations made by this report have been accepted by SA Health and an action plan has been developed.

Steps stemming from these recommendations include the referral of several clinicians to the Australian Health Practitioner Regulation Agency and targeted safety learning systems training for medical officers in the Central Adelaide LHN. Over 25 per cent of junior medical staff have undertaken this targeted training over June. Additionally, almost 3,000 staff members in the Central Adelaide LHN have taken open disclosure training as of 15 June.

This training educates clinicians about the best way to communicate with patients and their families after an adverse event and the process of open disclosure. This training will help prevent any patients who undergo adverse events and their family members from having their anguish and pain compounded by inappropriate and non patient-centred responses by staff, including clinicians. The Coroner is also undertaking an investigation into the deaths of some patients who had been subjected to the underdosing.

I am confident that the full undertaking of these important steps, in addition to the 17 recommendations of this committee, will ensure that a mistake of this magnitude and the subsequent level of ineptitude within the LHNs will never occur again.

The Hon. J.A. DARLEY (17:07): I am pleased to rise to speak to the report of the Select Committee on Chemotherapy Dosing Errors. The committee was established to inquire into the dosing errors which occurred at the Royal Adelaide Hospital and the Flinders Medical Centre in 2014 and 2015, with particular focus on what contributed to the error, the response from SA Health and the government, the suitability of SA Health's risk management and the impact this risk management had on affected patients.

Evidence heard by the committee really painted a bleak picture of the entire debacle. It was not only the fact that such a crucial mistake had been made, it was also the subsequent mishandling of the matter. The committee found that a mistake was made because proper protocols within SA Health were not followed. Not only were they not followed, it became clear to the committee that staff, including management, had little or no knowledge of the protocols. Clearly, there is room for improvement there.

Once the mistake had been identified, protocols to report the error were also not followed. As a result, underdosing continued for some patients. When patients were advised or discovered that they had not been receiving the correct dosage, the manner in which they were treated is, quite frankly, appalling. No information was provided to them, nor were any notes made on their medical files that they were the victim of underdosing and would require more intensive medical monitoring.

Some patients were told via the media of how widespread the problem was, and others were forced to sign a gag order as part of receiving their compensation. This was incredibly insensitive, as comfort and support could have been found in other patients who were experiencing the same issues. Psychologically this would have been invaluable to patients during their time of need.

Patients overwhelmingly reported that SA Health's handling of the matter lacked empathy and sensitivity. The government seemed more concerned about covering themselves rather than what was best for the patients, patients that had already been through quite a traumatic event.

Patients gave evidence that they faced a fight throughout every step of the process. Even though the government had made public statements that the matter had been addressed, in reality, issues continued and it was often not until there was further scrutiny through the media that things got moving. This is clearly not what is needed at a time when a person is trying to fight cancer. The last thing they want is protracted argument with SA Health and the government over compensation, reimbursement of legal fees or even an apology. This is especially so given that they know their time with their family is limited and precious.

The committee has made a number of recommendations and, frankly, it cannot be difficult to improve on how this entire matter was dealt with. I only hope that the report will give some comfort to the victims and their families who have struggled long enough with this issue and provide impetus for the government to implement changes in line with the recommendations.

The Hon. J.S.L. DAWKINS (17:10): I rise to support the motion to note the report. Can I say at the outset that I have served on a number of select committees on some issues that were of concern to a lot of the members of the committees and to the general public, but I think this inquiry probably brought up the most disturbing and distressing evidence about the manner in which some members of the South Australia community were treated in the SA Health system that I have ever been aware of.

The inquiry was initiated by a motion in this house of the Hon. John Darley. The committee was ably chaired by the Hon. Andrew McLachlan, and I served on the committee together with the Hon. Gail Gago, who obviously has a great depth of knowledge of working in the health system. We were served by Mr Anthony Beasley as secretary and Ms Carmel Young as the research officer.

In its very early stages, the inquiry highlighted some very ordinary culture in SA Health. I was concerned at various stages of the inquiry that, despite the determination of some in SA Health and the dedication towards that, there were other areas of SA Health that are absolutely determined to not change culture. That is something that can happen in a lot of bureaucracies and it happens in some bureaucracies outside government. I think we have all been aware of that, but the minister in question time only today used the words 'failure' and 'failings'. These were words he used to describe his impressions of this matter.

I would just say that we were concerned about the lack of response to a number of aspects of this very disturbing matter and the way in which some very good members of the South Australian community were treated. I very much hope that those cultural matters are changing. I think it is important. I just want to highlight a few of the key findings that the committee has put in this report. I do so without wanting to repeat things my colleagues have said, but from my stance, I think these are worth putting on the record.

The affected patients and their families were adversely affected by the treatment they received from SA Health and SAicorp when seeking compensation. It was unacceptable to impose on patients who were gravely ill, and who had been subjected to a severe medical error, the additional burden of getting lawyers to make claims as well as enduring the prospect of ongoing and potentially long-term litigation.

I think the approach by SA Health and SAicorp demonstrated a lack of compassion and appreciation of the additional psychological and physical burden placed on patients and their families by the manner of these actions. We certainly saw in the evidence given to us the psychological impacts that had been placed on these people as well as the obvious medical impacts. Overall, I think the response to the incidents by SA Health lacked a holistic approach to coordinated care. After the dosing error, the treatment of the patients was identified as being disrespectful, lacking a sense of empathy and any understanding of their pain and suffering.

Of course, there were the significant delays. I was gobsmacked by the fact that a number of officers of SA Health could not seem to explain the great delays in the discovery of these errors and the delivery of that information not only to the patients but up the stream in the department. It still distresses me that some people seem to think that was okay.

One aspect I paid particular attention to was that the appointment of care coordinators was not offered to patients early enough after the treatment errors were discovered. In fact, I think when the department came to us and indicated in evidence that this had been done, it was almost like it was a great novel idea to do this. To me, there was a great underestimation of the psychological needs of the patients and the psychological burden that was placed on their families, particularly with the increasing information that was coming out in the media.

We do not want these things to happen in the future but, unfortunately, we do have human error. Where there are errors detected, they need to be communicated early and people need to be able to have one person who they can go to for their particular needs.

I was concerned that the directive by the then CEO of SA Health that a root cause analysis be conducted seemed to be determined as unnecessary by both of the LHNs involved, and there seemed to be a lack of monitoring of this directive by the SA Health safety and quality unit. There were certainly no clear lines of communication across the LHNs, SA Pathology and SA Health. In fact, I think the lines of communication could not have been more unclear. Many of us were disturbed by the fact that there was almost no communication.

In earlier contributions, members spoke about the letter of apology that was sent to patients. It was inadequate. It was certainly sent way too late, but it was also regarded as being disrespectful, lacking in empathy or any understanding of what these people and the people close to them had gone through.

In conclusion, I think this whole matter has been riddled with delays and with, as I said, that lack of communication. The Hon. Mr McLachlan referred to the fact that we have had very senior staff, such as CEOs and people paid significant amounts of money, who have moved on and seem to have a total disregard for what happened behind them.

The amount of movement of senior staff in this whole sector during the period of our inquiry I thought was remarkable and disturbing. I will say that I do trust that SA Health is making changes, not only to avoid these errors as much as possible but also to make sure that the protocols around dealing with errors are improved. Obviously, there have been many reviews done that have made recommendations in that area.

I started off by saying how distressing a lot of the evidence, and I think the attitudes from some in the department to these issues, was to me. During the earlier period of this inquiry, I was involved in a fundraising activity with people who work in the health system, who work for SA Health in the Gawler area, people who are very good people on the ground—nurses and other people in that area—who were distressed by the disregard and the way in which this impacted on the reputation of the jobs that they do.

I think that that is something that we need to take into account. Those people, the people who look after us when we go to hospital or in other scenarios are out there every day, not on the big high salaries, and they were very distressed at the way in which these things had happened and of course were in front of the media daily for a very long time.

With those words, once again I thank my colleagues on the committee. As is generally the case with committees of this place, I think it was a very constructive committee in the way that it worked. Once again, I thank my colleagues and the staff of the committee and commend the report to the council.

Debate adjourned on motion of Hon. S.G. Wade.