Chemotherapy inquiry told bungle could happen again as South Australian medical staff fail on safety protocols

THE architect of the inquiry into the chemotherapy scandal has warned that another major mistake could occur because staff fail to follow safety procedures.

Prof Villis Marshall says staff are frightened to report errors and a cultural shift is needed in SA Health. Picture: Scott Campbell

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THE architect of the inquiry into the chemotherapy scandal warns another major mistake is possible because staff have failed to follow safety procedures.

Professor Villis Marshall has told a parliamentary inquiry that noncompliance with hospital protocols risked causing another devastating mistake.

He said the medical staff of the haematology unit — at the centre of the chemotherapy bungle at two Adelaide hospitals — failed to follow the correct safety learning processes and staff in other areas may behave in a similar way.

“On that basis there would be the potential of finding similar issues (in other medical areas), although I can’t say that with certainty,” Prof Marshall told the inquiry on Tuesday.

“I would’ve thought this is something – one would hope – the institutions (SA Health) would be looking at.

“If it is happening with one group of medical staff ... you need to look at what is going on.”

The review was prompted after TheAdvertiser last year revealed 10 seriously ill cancer patients at the Royal Adelaide Hospital and Flinders Medical Centre were given half their required chemotherapy dose.

Prof Villis Marshall during his time as director of surgical speciality services at Royal Adelaide Hospital.

Prof Marshall said staff were frightened to report errors in fear of retribution and a cultural shift was needed in SA Health.

“Reporting errors — everyone is expected to do that, even from the most junior member of staff needs to show some leadership as far as that is concerned,” he said.

He said the handling of the patients also fell short of appropriate standards and SA Health’s apology letter had been watered down by insurers.

Prof Marshall said insurers had intervened and changed the letter, and the resulting letter sent to patients “lacked empathy and could be seen as offensive”.

He said hospital staff had also not grasped the gravity of the situation and an early request by the department’s chief executive to investigate it was dismissed as it was believed to be a “clerical mistake”.

Prof Marshall, chairman of the Australian Commission on Safety and Quality in Healthcare, fronted the inquiry after leading an independent review into the dosing scandal.

Andrew Knox, one of the ten patients given half their required chemo dose. Picture Campbell Brodie.

One of the affected patients, Andrew Knox, told The Advertiser that Prof Marshall had revealed to him if medical policies were followed correctly in his case, it would have made a “huge difference”.

“There is no consequence for noncompliance and potentially killing people,” Mr Knox said.

“The minister can’t sit on his hands and watch all these things go by, nor can the Premier, and just say they’re powerless.”

Health Minister Jack Snelling denied there was a cultural problem in SA Health and said the medical staff were constantly reminded of their obligations to report errors.

The Government had referred eight clinicians to the national regulator for investigation, Mr Snelling said. “Structural changes” to haematology at the RAH were close to being finalised as part of the review’s recommendations, he said.

However, shadow health minister Stephen Wade said Prof Marshall’s comments highlighted another need for a judicial inquiry into SA Health.

“The parliamentary committee today heard damning evidence of systemic failures in culture and leadership in SA Health,” Mr Wade said.

“The head of the department asked for a full investigation to be instituted and that was dismissed at departmental level. This is clear defiance.

“There’s a defiance of protocols, a defiance of culture, and that can only lead to great risk to patients.”

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