RAH power failure cause revealed: Crucial generator ran out of fuel

THE real reason for the RAH power failure that left surgeons in the dark mid-operation has now been revealed — and the Government says it may have been intentionally misled with the original, incorrect explanation.

• Surgeon’s diagnosis: Someone could have died
• Power fails at new RAH, disrupting surgeries

THE Royal Adelaide Hospital power failure that left surgeons in the dark mid-operation on Wednesday occurred when a crucial generator “ran out of petrol”.

Furious Health Minister Peter Malinauskas says hospital operator Celsus had initially given him “inaccurate information” on the bungle.

Parts of the RAH were blacked out for 17 minutes on Wednesday morning.

That information had led to the minister announcing the life-threatening blunder was caused by a single software problem.

Celsus released a statement on Thursday, signed by chairman James Bramley, conceding that it “provided inaccurate and incomplete advice to SA Health on the circumstances behind the outage”.

It is charging taxpayers $1 million a day under its 35-year contract to build and operate the RAH.

With even Mr Malinauskas conceding he is still not sure of the full circumstances, it appears Celsus workers ignored a warning alarm that a diesel tank to a back-up generator being tested was running dry due to a faulty fuel pump, assuming the generator would switch back to mains power — but it did not.

“The generator ran out of petrol,” Mr Malinauskas said.

Celsus now blames “two software faults” as it prepares a report for the Government, while the Government in turn has rushed in its own engineers to oversee the power supply of the $2.3 billion hospital.

The information provided to Mr Malinauskas after the event made no mention of the generator running out of fuel.

“They provided us inaccurate information, whether they did that deliberately or not, I am not aware,” he said. “That is something we are looking at.”

Health Minister Peter Malinauskas. Picture: Tricia Watkinson

WHAT WENT WRONG

■ SIX back-up generators undergo routine monthly testing on Wednesday morning to ensure they can deal with a blackout.

■ IT is part of the RAH’s “island mode” plan which allows the hospital to function self-sustainably as a medical refuge with its own power and water supplies for several days in the event of a catastrophe in Adelaide.

■ DURING the test, a pump that feeds fuel from the main tank to a smaller day tank to power one generator did not work — which was blamed on a software glitch.

■ AFTER 2 hours, 52 minutes, the day tank runs out of fuel and despite an alarm sounding no action is taken.

■ THIS is because it is supposed to automatically switch back to mains power when it runs dry — but a second software glitch occurred and the system did not revert to the mains power source. This led to the power failure at 10.52am which lasts 17 minutes and affects one-seventh of the hospital, the northeast E Block.

 

A surgical theatre room at the new Royal Adelaide Hospital. Picture: AAP / Morgan Sette

When the power failed, two surgical procedures were plunged into darkness, three people were trapped in lifts, patients undergoing radiotherapy had their treatment halted, a dialysis patient’s treatment was paused, and a patient injected with radioactive dye for a PET scan was rushed to another building.

A colonoscopy in progress was completed in semi-darkness, while a complex removal of a bile duct stone on an elderly patient also was completed despite three crucial monitors going blank, while “keyhole” instruments were inside the patient.

In the chaotic aftermath of the blackout, when the power returned, surgeons were told to proceed with operations — but that order was suddenly rescinded after at least two patients had been put under full anaesthesia.

These two operations went ahead after officials decided it was in the patients’ best interests to proceed.

Australian Medical Association Associate Professor William Tam was in the middle of performing surgery when the power was lost. Picture: Tom Huntley

E Block, which covers one-seventh of the RAH, was affected by the outage including:

■  Two operating theatres with surgery underway

■  Radiotherapy

■  Nuclear Medicine

■  Several outpatients clinics

■  Cancer day treatment

■  Cardiology

■  General surgery

■  Palliative care

■  Respiratory

■  General medicine.

The Intensive Care Unit and Emergency Department were not affected because they are not in E Block.

Senior doctors say patients could have died and they have demanded reliable power to hospitals.

Australian Medical Association state president William Tam, who was one of two doctors caught in mid-surgery when the blackout occurred, said the situation in the operating theatre was extremely tense.

“Doctors and patients must have confidence that the new hospital is safe,” he said.

Fortunately, the anaesthetic supply was not affected and after conferring with colleagues, he managed to complete the operation.

Prof Tam said if doctors had been performing more complex surgery, the result “would have been disastrous”.

SA Health chief executive Vickie Kaminski. Picture: Stephen Laffer

SA Health chief executive Vickie Kaminski said the generator running out of fuel was different to the situation when a fuel generator ran dry at Flinders Medical Centre, leading to the loss of 50 human embryos in the fertility clinic.

In that case, human error was blamed — a switch was left on manual instead of automatic after a test, allowing a diesel tank to run dry during the statewide blackout.

Ms Kaminski apologised to families affected, noting that some people were being prepped for surgery when the lights went out.

“We are told during the test of the generator the low fuel alarm went off and the person doing the test did not stop doing the test at that point,” she said.

Ms Kaminski emphasised that the test was done to ensure back up generators could carry the full load in an emergency.

Opposition Leader Steven Marshall said it “beggars belief” the Government would approve a testing system while patients are undergoing surgery.

He labelled South Australia’s latest health system incident a debacle and said the outage put patient’s lives in danger.

Mr Malinauskas said this was to ensure the back-up system could cope with peak demand — a point accepted by the AMA’s Prof Tam who also suggested it would be good if surgeons were told that tests of the power system were underway while they were operating.

South Australian Salaried Medical Officers Association past president Dr David Pope. Picture: Kelly Barnes/The Australian

South Australian Salaried Medical Officers Association past president Dr David Pope said the outage was “something that shouldn’t happen” and “absolutely” could have resulted in patient deaths.

“If you’re depending on various machines to keep you alive or in a delicate procedure, there are many ways a patient can come to serious harm and ultimately death (when the power is cut),” he said.

“Patients in intensive care entirely depend on electricity being available to run all the machinery.”

Dr Pope said “doctors weren’t informed that this (the maintenance) was even occurring”.

“If they’re testing systems and software that could result in outages (it should be) routine that clinical staff are aware of that so they can adjust what they’re doing at the time,” he said.