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House of Assembly - Fifty-First Parliament, Third Session (51-3)
2008-09-10 Daily Xml
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ROYAL ADELAIDE HOSPITAL RADIATION ONCOLOGY REVIEW

The Hon. J.D. HILL (Kaurna—Minister for Health, Minister for the Southern Suburbs, Minister Assisting the Premier in the Arts) (14:41): I seek leave to make a ministerial statement.

Leave granted.

The Hon. J.D. HILL: On 16 July 2008, the Chief Executive of the Department of Health received a complaint about radiation oncology treatment provided at the Royal Adelaide Hospital from July 2004 to July 2006. The complaint alleged that one of five linear accelerators at the hospital delivered a radiation dose 5 per cent lower than prescribed during the two-year period. Within days the government instigated an independent review to be led by Professor Geoff Delaney, a radiation oncologist from New South Wales. This report has now been completed, and I now table it and associated documents.

The panel was asked to consider whether this under-dosing had any clinical impact on the patients treated and whether the hospital implemented appropriate risk management strategies following the discovery of the under-dosing.

The review panel has concluded that the under-dose is unlikely to have had clinical significance for the vast majority of the 869 patients treated on the machine in question. However, the panel believes that for a small number of patients in three different tumour groups there may be a small but real clinical significance, and these patients should consult their oncologist.

The hospital has identified seven patients who fall into this group. The hospital has contacted the oncologists of these seven patients to ensure that they have ongoing checks on their future health, though the patients will not require additional treatment at this stage. The oncologists are contacting these patients today. The other patients have been sent a letter today assuring them that the report does not find that they have cause for concern regarding their treatment. However, any of those patients who have concerns can contact the Royal Adelaide Hospital for further information or assessment.

The review also makes 14 recommendations. I have asked the Department of Health to take immediate actions to implement all of those recommendations. One of the recommendations is that the report on the incident should be sent to the manufacturers of the treatment planning system to ensure that an extra alert is introduced into the system to help prevent such an error from occurring again. This notification will be happening today.

Another recommendation is to address issues relating to the experience and the medical physics workforce. The report notes that recruitment is difficult due to a national and an international shortage of radiation oncology medical physicists. SA Health has already taken immediate steps to address this and is working to recruit six additional physicists.

South Australians can be reassured that the report confirms that radiation oncology is a very safe form of treatment compared to other medical interventions. The report advises that, although the overall clinical impact might be small, an error such as this provides a significant warning for a potential more serious error in the future and therefore should be considered serious. That is why the government has initiated a further review, to be conducted by Mr Ian Kowalick, that will inquire into the actions taken by the hospital management in response to this incident. I will provide that report to the house after its completion.

I extend my sympathies to the patients and families who have endured stress and uncertainty during this process. I hope this report will be helpful to them and address many of their concerns.

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