Doctor reports on four baby deaths at Women’s and Children’s Hospital knocked back because of technicality
Doctors warning more babies would die at the WCH because of a lack of cardiac surgery were prevented by bureaucrats from recording the deaths.
SA News
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Doctors trying to raise the alert about four babies dying in a month at the Women’s and Children’s Hospital blamed on lack of a cardiac surgery unit had their reports rejected because “there is no safety issue if there is no service”.
The reports to SA Health’s Safety Learning System (SLS) – where reports of adverse events and near-misses are logged in an effort to avoid future similar incidents – were knocked back on a technicality.
The doctors say because the WCH does not have a cardiac surgery unit, or a extracorporeal membrane oxygenation (ECMO) life support service, they were informed there is no system about which to report a failure.
SA Salaried Medical Officers Association senior industrial officer Bernadette Mulholland likened it to the deadly chemotherapy bungle – after that scandal the Coroner called for the SLS “to abandoned and be replaced by an adverse event reporting system”
A subsequent inquiry into the SLS initiated in February has not yet reported.
“The SLS reports that have been put in initially have been rejected,” Ms Mulholland said. “They have been rejected on the basis that we do not have an ECMO service here in South Australia and, therefore, they can be rejected.
“This is after the review of chemotherapy, a very similar situation, where we were told that a review of the SLS would be conducted.”
A report to SafeWork SA following an inspection of the WCH’s paediatric intensive care unit last Thursday by SASMOA paints a devastating picture of the risk to vulnerable babies.
It notes the two union inspectors “were told by doctors that although this situation was and is known to (management) nothing has been done to address the process meaning more babies will die.”
Another baby needing cardiac surgery died the following day, the fourth in four weeks.
“The inspectors were told by the doctors that management has rejected SLS reports submitted by the doctors because the safety issue relates to ECMO,” the report states.
“This has left frontline clinicians distressed.
“The inspectors were advised by doctors, SLS is the only system available to report patient incidences and health and safety incidences.
“If the SLS is unable to be accessed by workers, then there is no formal reporting system to log when a significant safety incident occurs – this includes delays in lifesaving care.”
Doctors say if an SLS is rejected, management say “open disclosure” with the family including the parents of the deceased baby is not required, nor is the matter recorded as being so serious it needs to be drawn to the attention of the Minister, the report notes.
It also notes one doctor says he was told by management that “because the services were not available at the WCH the SLS report would be rejected as the system would not record such a safety incident” and that “there could be no safety issue if there is no service”.
WCHN Medical Director of Paediatric Medicine and Senior Cardiologist, Dr Gavin Wheaton told The Advertiser: “Every clinical incident reported to our Safety Learning System is treated very seriously and is thoroughly reviewed.
“All clinical incidents are reviewed by senior clinicians. Any change to the rating of an incident is made by a senior clinician, in consultation with the Safety and Quality Unit.
“Delivering safe and high-quality care to our patients is, and has always been, our number one priority. All staff are encouraged to report any patient incident where they believe normal clinical processes were not followed.”
SA-BEST MLC and chair of parliament’s health committee, Connie Bonaros, has called for an independent inquiry into the four deaths.
“This is a deeply alarming and disturbing revelation by SASMOA – and its investigation into the matter makes for distressing reading,” she said.
“It indicates potentially-fatal excuses are being made by bureaucrats to reject clinicians reporting mechanisms to ensure all patient-related information is fed into a department-wide database – it’s scandalous.
“The very essence of the Safety Learning System is to enable all SA Heath services to record, manage, investigate and analyse patient incidents. Yet again, here is another classic example of frontline clinicians raising the red flag and their concerns are being literally snubbed by the bureaucrats.
“We know what happened with the chemo bungle – people died.
“Babies are already allegedly dying because the WCH doesn’t provide paediatric cardiac surgery services – deaths that clinicians say are avoidable.
“I call on the Minister to intervene as a matter of urgency.”
SASMOA’s report to WorkSafe SA says WCH management have contravened multiple sections of the Work Health and Safety Act and calls for an independent review.
SafeWork SA confirmed they are assessing the report noting “this does not mean there is an actual contravention.”
