Coroner Mark Johns labels review committees within SA Health as ‘an elaborate secret system’ during inquest into death of girl, 10

STATE Coroner Mark Johns has labelled 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.

SA State Coroner Mark Johns, pictured in his office.

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STATE Coroner Mark Johns has labelled 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 they 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.

“It’s alarming on its face.”

Mr Johns lashed out at the system after a Women’s and Children’s Hospital (WCH) lawyer tried to hand up part of a report undertaken by a mortality review committee after Briony Klingberg’s death on January 18, 2015.

But he would not accept the document, saying it wasn’t even clear who authored the report.

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

Bridget Klingberg leaves the Coroner’s Court after giving evidence about the tragic death of her 10-year-old daughter Briony.

Her condition went undiagnosed until an autopsy showed she died of multi-organ failure due to herpes simplex virus, a common illness which causes ulcers to form in the mouth cavity.

An SA Health spokeswoman said all Australian health departments had laws in place that “protects information and documents produced to and by committees that make safety and quality assessments”.

“This is vital in encouraging open reporting of adverse events in the health care system and ensuring improvements are made to health services and practices,” she said.

“All recommendations of these committees are available publically, including to the Coroner.”

Mr Johns’ comments came eight days after his deputy, Anthony Schapel, criticised 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.

Her death followed that of Monique Hooper under similar circumstances three years earlier.

In his findings into Ms Paltridge’s death on May 25, Mr Schapel said legislation — successfully used by SA Health to prevent the details of a committee’s review into Ms Hooper’s death being publicly released — was contradictory to the court’s objectives to investigate and prevent further deaths.

He said the legislation appeared to provide health practitioners with an opportunity to be more frank than they might otherwise be if information they provided to a committee was made public.

“These provisions operate in a medical environment where one would think that a clinician’s professionalism would prove to be sufficient impetus for that person to conduct themselves with complete candour in such an inquiry,” he said.

“Indeed, some might say that complete candour would most likely be secured by the oath. Yet, it is thought, secrecy is an intrinsic ingredient to frankness.”

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

He said there were other reasons why “blanket secrecy” in connection with internal reviews into adverse medical events was undesirable.