Select Committee on Chemotherapy Dosing Errors

Adjourned debate on motion of Hon. A.L. McLachlan:

That the report of the select committee be noted.

(Continued from 15 November 2017.)

The Hon. S.G. WADE (21:02): I rise to speak to the motion that the report of the Select Committee on Chemotherapy Dosing Errors be noted. This is a very important and timely report that not only unpacks significant failures in the treatment of 10 South Australians with acute myeloid leukaemia, but also investigates the aftermath of those errors, including the appalling way the Weatherill Labor government and key figures in SA Health attempted to cover up and play down what happened in the weeks and months that followed the discovery of the errors.

Getting to the bottom of what happened and why has been and continues to be a bitter and painful journey for the 10 victims and their families. They are South Australians who have had to fight tooth and nail for information and understanding that they have every right to have and which the government should have freely provided to them at the earliest opportunity.

Notwithstanding that the underdosing errors occurred in late 2014 and early 2015, it was not until August 2015, after accounts of the underdosing first appeared in the media, that the process of working out what had gone wrong and why began in earnest. Until then this government and key people in the health department had done their best to keep what happened under wraps and, in some instances, buy the silence of the victims.

I am sure we all recall the sloppy and inaccurate assurances that the then minister for health and senior clinicians gave when the story first broke, including the minister's false claim that none of the victims had died. I am sure we all recall the Premier's claim at the time that the victims and their families were being given all the support they needed. The select committee's findings well and truly unpack the emptiness of that claim.

In response to the story breaking in the media, an independent review headed by Professor Villis Marshall was established. That review, completed in November 2015, confirmed that significant clinical governance failures had occurred and that senior staff had ignored SA Health's incident management processes and open disclosure policies.

This select committee was the next inquiry to be established. In March 2016, it was established and, it must be noted, established without the support of this government. Because of the hard work of the select committee and, more importantly, the courage and tenacity of the victims and their families, parliament's understanding and, for that matter, South Australia's understanding of what happened and why has significantly increased. For example, because of the work of the select committee, we now know that the direction given by the then CEO of SA Health that a recourse analysis be conducted was ignored. Through the work of the select committee we now know that the government and SA Health's failure to act to implement the recommendations of the earlier dosing failures left the way open for further errors to occur.

Through the work of the select committee we have begun to understand how SA Health's decision to roll out EPAS, its problem-plagued electronic patient health record system, derailed efforts to set up an electronic system for managing chemotherapy protocols. The committee's findings chronicle serial disobedience by both clinicians and administrators and the failure to implement multiple reports, guidelines and directives. How, we must ask, did all this go on apparently unnoticed on the watch of this government?

We now know that the culture went far beyond this isolated chemotherapy blunder. Through the agitation of the victims, Mr Pehm of the Australian Commission on Quality and Safety in Health Care was tasked with a further investigation to follow on from the Marshall report. Mr Pehm made a finding that there was 'a breathtaking contempt for good clinical governance'. That led to another report. This one focused on the Central Adelaide Local Health Network that confirmed Mr Pehm's view and postulated that it would take five years to establish proper governance in the one network.

The committee's findings bring together these and other historic reports and paint a highly disturbing picture of a culture in our public health system that is completely unacceptable. Notwithstanding all of these discoveries and the government's promises to take appropriate action, a Crown Solicitor's report into disciplinary matters promised by the then CEO of SA Health back in mid-2016 remains unfinished. This is completely unacceptable. It is completely unacceptable and something that frustrates and torments the families who are currently enduring disturbing revelations coming to light as the ongoing coronial inquiry runs its course.

While as a council we are thankful for the work of the select committee, we cannot and must not think that this is the end of the matter. As a parliament, as a community, we have been here before. We must do all that we can to make sure that we do not find ourselves here again in a handful of years wondering why similar errors and cover-ups have happened once again.

I note that Crown law legal counsel acting for the minister before the Deputy Coroner in the coronial inquest continues to seek to exclude evidence from the coronial inquest. It is impossible for the families of the victims to reconcile that action with the government's so-called commitment to open disclosure. Understandably, the ministers want to know the full extent of the minister's instructions. On behalf of the victims' families, I call on the minister to do two things: to explain his instructions to legal counsel and to set a deadline for the completion and release of the Crown Solicitor's disciplinary report.

Finally, I want to conclude these brief remarks with a heartfelt thanks to those victims and their families who gave evidence to the committee, some of whom have since, sadly, died. I am compelled to particularly thank and honour Andrew Knox. A victim himself, he has risen up on behalf of his family, other victims and all South Australians to with great tenacity and great courage pursue these issues to make sure that what has happened to him does not happen to others. To him I say thank you; to him we are eternally indebted. I commend the motion to the house and thank the select committee for its work.

The Hon. A.L. McLACHLAN (21:09): I wish to thank all members who made a contribution. I state my thanks again to the members of the committee who served alongside me. I also echo the words of the Hon. Mr Wade and thank the families and the victims for their courage in attending the committee, often with great media interest, to tell their sorry tale. Not only do I thank them but I commend them for their courage. I also acknowledge, on behalf of the committee, their pain and suffering, which was immense. I hope that the work of this select committee will result in better healthcare delivery for all South Australians and, when an error is made, far better care and consideration of those affected.

Motion carried.