David Penberthy: Don’t allow doctors to bury their mistakes

OUR state’s treatment of how we treat our most vulnerable — including children who have been abused or people with a life-threatening medical condition — is the ultimate test, writes David Penberthy.

Andrew Knox, one of 10 patients underdosed in his chemotherapy treatment, gives evidence at the Parliamentary inquiry. Picture Campbell Brodie.

• Chemo victims accept compensation reluctantly

IT is said that the ultimate test of any decent society is how it treats its most vulnerable.

The first people you would include in that category are children who have been abused by derelict parents and step-parents.

You would also include people who have been diagnosed with a life-threatening medical condition, only to have their condition worsened — or their life even ended — because of errors in their medical treatment.

In this state we have had a Royal Commission into the former. And we are throwing hush money at the latter.

The circumstances surrounding the death of little Chloe Valentine were the subject of a coronial inquest. Day after day, a procession of public servants, some of them entry-level staff, were called to give evidence. They were photographed. They were featured on the evening news. They were named and, in some cases, shamed over the role they played in the lead-up to that child’s death.

The Valentine case led to the fullest possible inquiry into child protection, a turbocharged Royal Commission examining every aspect of the workings of Families SA — staffing and rostering, the skill set of employees, the philosophies guiding the department.

There are now three scandalous cases in this state where the health system and medical profession have wrecked families through their incompetence. The public knows nothing about the identities or conduct of those involved.

Like most members of the community, I have the deepest respect for the medical profession. As a general rule, the people who work as specialists are exceedingly intelligent and hardworking, having devoted many years of their lives through study and long hours to protecting and saving lives.

One of the reasons they enjoy such high levels of remuneration is because of the risk their work involves, which means a lot of their salary vanishes instantly in the form of insurance premiums.

But like any other profession, there are undoubtedly some people within the medical profession who simply aren’t that good at the job. Equally, there are those who are normally good at their job, but on the rare occasion when something goes wrong, fall victim to the human tendency for ducking the blame.

The medicos who fall into this category are very much in the right line of work. The system does a great job of protecting them.

If you are going to have a Royal Commission into a child protection department which touches a narrow spectrum of the community, surely there are grounds for a Royal Commission into those cases which have shamed a public health system which almost every South Australian will use at some stage in their lives?

The Health Minister Jack Snelling is adamant that investigations into mistakes within the health system must be kept confidential. He says this enables an immediate no-holds-barred internal discussion by the relevant review committee as to what went wrong, so the problem can be rectified as swiftly as possible.

Many people don’t buy that line of argument, and would counter that it looks more like a protection racket than a system aimed at guarding against future errors.

Problematically for the State Government, they include the state’s two most senior coroners.

This month, Chief Coroner Mark Johns described the review committees within SA Health as “an elaborate secret system” during his inquest into the death of a 10-year-old girl, whose common illness went undiagnosed.

He said the activities performed by review committees within the health system were mostly kept confidential and did not have an obligation to report any admissions of wrongdoing during their review process to prosecuting authorities.

“It’s a mystery how these committees work and who, if anyone, manages their activities,” he told the inquest into the death of Briony Klingberg, whose life could have been saved if she had been given a simple antiviral medication.

“It’s alarming on its face.”

Briony died five days after being discharged from the WCH emergency department with a sore throat and ulcers on her pharynx.

The state’s Deputy Coroner, Anthony Schapel, also condemned similar secrecy surrounding a review into a pregnant woman’s death at the same hospital. Mellanie Joanne Paltridge died at the WCH during surgery, having suffered an undiagnosed case of ruptured splenic artery aneurysm.

Mr Schapel said legislation — successfully used by SA Health to prevent the details of a committee’s review into another woman, Monique Hooper’s death being publicly released — was contradictory to the court’s objectives to investigate and prevent further deaths.

“It is difficult to think of any other profession where its members are furnished with such an indulgence,” Mr Schapel said.

At least in these cases the health system appears to have been motivated by a desire to find out what went wrong. Not so in the case of the 10 leukaemia patients, administered less than half the required dose of chemotherapy drugs, whose mistreatment was compounded by the subsequent cover-up within the health system of this gravest of errors. It was, to be blunt, a disgraceful arse-covering exercise.

The Government can keep arguing that the system is working just fine. It is making them look patsies. To use a Keatingism, it is making them look like they are being played by one of the most powerful unions in the land.