Legislative Council Fifty-Fifth Parliament, First Session (55-1) 55 1 Parliament of South Australia Legislative Council published Answers to Questions Answers to Questions Coroner's Office Coroner's Office The Hon. S.L. GAME Legislative Council Coroner's Office 316 The Hon. S.L. GAME ().18 October 2023). In reply to Hon S.L. Game MLC (18 October 2023): Can the Minister for Health and Wellbeing advise: 1.	Has an adverse event reporting system been implemented in hospitals and medical centres for use by staff as recommended in paragraph 27.10 on pages 198-199 in the 2019 Coroners Findings report 'Inquest into the Deaths of MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol' which resulted from the inquest into these chemotherapy under-dosing deaths? 2.	If the recommended adverse event reporting system has not been implemented, is there a plan to implement a system to replace the Safety Learning System, deemed by the Deputy State Coroner to be not fit for purpose? 3.	If the Safety Learning System is not to be replaced, is there any intention to devise and implement a separate adverse event reporting system supplementary to the Safety Learning System that would satisfy the Deputy State Coroner's recommendation? 4.	If a plan to implement an adverse event system exists, when will it be implemented? 5.	If the recommended adverse event system, or similar, is already in place, where can we find comprehensive details, such as its inception date, scope, and current users? The Hon. K.J. MAHER Legislative Council Minister for Aboriginal Affairs Attorney-General Minister for Industrial Relations and Public Sector Coroner's Office The Hon. K.J. MAHER (Minister for Aboriginal Affairs, Attorney-General, Minister for Industrial Relations and Public Sector): The Minister for Health and Wellbeing has advised SA Health commissioned a comprehensive independent review of the Safety Learning System in response to recommendation 2 in the 2019 Coroners Findings report 'Inquest into the Deaths of MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol'. In January 2020 Associate Professor Peter Hibbert, University of South Australia was commissioned to lead an independent review of SA Health's Safety Learning System. This independent review, which was publicly released on 23 October 2020 by the Marshall Liberal government, found that the Safety Learning System and its constituent modules are sufficiently flexible to deliver the changes sought by the Deputy State Coroner. SA Health accepted the recommendations made by the independent review team which related to the Safety Learning System governance, technical and cultural improvements to align with the intent of the Deputy Coroner's recommendation.