Chemo bungle: SA Health blasted in parliamentary report for handling of chemotherapy underdosing scandal

SA Health has been slammed for its “culture of blame, fear of retribution and inertia” in a parliamentary report into the chemotherapy underdosing scandal at two major Adelaide hospitals.

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SA HEALTH has been condemned for its “culture of blame, fear of retribution and inertia” in a parliamentary report that also highlighted the role of the media in uncovering the chemotherapy underdosing bungle at two major hospitals.

In the most outspoken and critical report so far on the damage done to the patients, the Report of the Select Committee on Chemotherapy Dosing Errors condemned SA Health for failing to investigate properly an event of such magnitude, and for waiting until the story became public.

“It should not have been necessary for the matter to be raised in the media for such an investigation and action to occur,” the committee found.

The committee, which was chaired by Liberal MLC Andrew McLachlan, could not rule on evidence from the seriously ill leukaemia patients who believed that the half dose of chemotherapy had damaged their health and recovery.

The medical impacts were being looked into separately by the coroner whose court this week will continue to hear evidence on the impact of the underdosing on the four patients who died.

Bronte Higham, who was one of the 10 chemo patients who were underdosed, giving evidence to the parliamentary inquiry. He has since died. Picture: Campbell Brodie

A much thinner chemo underdosing victim Andrew Knox after giving evidence in the coroner’s inquest. Picture: AAP/Dean Martin

Instead, the committee focused on the way patients were treated, which included their “painful and distressing experiences” with SA Health and the State Government’s insurer, SAICORP.

The extent of the psychological and physical impact on the patients and their families deeply moved the committee.

“This treatment error has had an adverse impact on their lives and the lives of their families,” the report said.

The committee found unequivocal evidence of systemic cultural problems, because of the error, and in the way the error was handled. This included inaccurate public statements made by the Minister of Health and the SA Health chief executive.

In August 2015 when The Advertiser broke the story of the chemotherapy bungle, then-Health Minister Jack Snelling said that no patient had died. It emerged later that one patient, Johanna Pinxteren, had relapsed and succumbed to the illness in June, two months earlier.

“SA Health’s failure to manage the public focus on the patients further exacerbated their pain and suffering,” the report said.

Staff turnover at SA Health was high at senior management level and in key clinical leadership positions, which affected its capabilities and had a negative impact on morale.

“The result is an unhealthy hierarchical organisational environment within SA Health resulting in a culture of blame, fear of retribution and inertia,” the report said.

Bronte Higham with his wife Ricki at home. Bronte has since died. Picture: Matt Turner

Anne Pinxteren, also known as Johanna, also died.

The committee, which included Labor MLC Gail Gago, took evidence from relapsed patient Bronte Higham only weeks before he died about the poor handling of compensation claims with patients being told to prepare for “a lengthy and expensive litigation process”.

“I am (a) dead man walking,” Mr Higham told the committee. “The victims and the families deserve compensation for this, because it has been just one big stuff up.”

Soon after, the Premier, Jay Weatherill intervened and compensation offers of $100,000 were made to all ten patients, or their surviving families.

The committee also targeted the letter of apology sent to patients as being inadequate and sent too late after the mistake was detected.

“ ... patients found the letter of apology to be disrespectful, lacking in empathy or an understanding of their pain and suffering,” the committee found.

SA Health staff were reported to be overwhelmed by the level of change, which included the move this year to the new RAH and the restructuring known as Transforming Health.

There were particular problems at senior levels that included “a pattern of obfuscation, inertia and disregard for SA Health policies and procedures by some senior clinicians and SA Health bureaucrats”.

The committee’s recommendations included setting up an audit team to make sure procedures and policies were followed, and appointing a single person to manage responses to a clinical incident.

It also called for a statewide chemotherapy protocol system to be expedited, which would have provided an additional level of checks.

Jack Snelling was health minister at the time The Advertiser broke the news of the chemo underdosing. Picture: Sam Wundke

While unable to say what clinical damage was done to the patients’ hopes of recovery, the committee was in no doubt at the devastation the mistake caused.

“Patients and their families have been left in a position where they will never know the true impact of the chemotherapy underdosing on their chances of survival,” the committee found. “The realisation that the error also prevented the opportunity to access further trials and studies was also a constant source of profound dismay for patients and their families.”

Public confidence in the South Australian public health system had to be restored and the potential for error within the complex field of chemotherapy had to be mitigated, it found.

But even two years later, it was greatly concerned at the lack of information about the training of senior medical staff who were the ones who most needed it.

Senior staff from the haematology departments at RAH and FMC are due to take the stand in the Coroner’s Court from next week.

Health Minister Peter Malinauskas said he would consider the report’s findings.

“What happened to these patients was unacceptable and represented a clear failing in the standards we expect,” he said.

“There have been numerous investigations into this incident. All the subsequent recommendations have been accepted and have either been implemented or are being progressed.”