‘Clunky’ hospital safety reporting uncovered amid culture concerns

An independent review into allegations of botched surgeries and a poor culture at Caboolture Hospital has called for staff empathy training and an overhaul of inadequate reporting methods within the country’s largest public health service.

Eminent South Australian surgeon Jim Sweeney’s review has also flagged a need for further investigation into two spikes of “unplanned returns” to operating theatres since April last year, after he was unable to adequately assess the safety and quality of surgical and intensive care.

Health Minister Yvette D’Ath says the review offers lessons for “all hospital and health services”.Credit: Google Street View

Media reporting about several cases – including a woman who had to endure 11 operations after she was left with a “football of organs” sticking outside her body following a caesarean section in which part of her bowel was sewn onto her abdomen wall – led the Metro North Hospital and Health Service to order the review in early September.

Finalised last week, the report was released by Metro North board chair Jim McGowan on Wednesday with a statement acknowledging criticisms about safety and reporting quality, and accepting all 19 recommendations.

The review team – featuring three other experts from the private and public health system, along with a law-based consumer representative – found no evidence of failures by individual surgeons or incidents of them operating outside their training.

But they did find “factions” had emerged in the workplace after 18 months of leadership disruptions.

Regular surveys suggested morale in the surgery and intensive care department had slipped this year compared to 2019, with later comments to the review team finding “poor leadership, [a] lack of trust and transparency” from past bullying and harassment.

Such a culture led to “ineffective participation and inadequate information” and feedback about safety and quality of care.

“This lack of enthusiasm resulted in safety and quality [being] perceived as meaning more work for staff, so actions were minimised rather than being viewed as opportunities for improvement,” the review found.

In an “overall positive” sign, general hospital mortality ratios were found to be below the national average, since mid-2019.

But two other recent Metro North reports highlighted a greater level of the highest-risk clinical incidents than seen at the other three health service hospitals in the Metro North area.

Those reports also found spikes in unplanned returns to operating theatres in April 2020 and March this year, with more investigation needed.

The review was critical of formal safety incident reporting, which missed important contributing factors, including three instances in which staff failed to recognise that a patient may have been experiencing sepsis, two missed diagnoses, and one delayed diagnosis.

“The current safety and quality health informatics systems used at Caboolture Hospital (and many other hospitals) are ‘clunky’ and lack the maturity of financial reporting systems used for the purposes of corporate governance,” the review found.

The reporting and collating of patient feedback was also found to be lacking, with its monitoring and use by the surgery and intensive care team to improve care deemed “unsatisfactory”.

Speaking to reporters on Wednesday afternoon, Mr McGowan said he would be held accountable for the rollout of recommendations, including clinical and communication training for staff, along with better reporting methods of both safety issues and patient complaints.

Responding to questions about the culture at the hospital, he said there had been recent management structure changes and resignations.

“You can come back here in eight months’ time and check to see that that’s happened because I am determined,” he said of the health service’s plan to respond.

Health Minister Yvette D’Ath flagged the review’s imminent publication two hours ahead of time at a press conference, where she deferred questions on the detail to Mr McGowan but said there would be lessons to be considered “by all the hospital and health services”.

LNP Opposition Leader David Crisafulli said he and his colleagues, who held town hall meetings for people with complaints about the hospital, would go through the report before addressing the media on Thursday and calling for Ms D’Ath to do the same.

“It’s either a rogue surgeon or a broken system … one way or another, someone has got to be held accountable,” he said.

An independent review into complaints from women about complications after caesareans at the Mackay Base Hospital was ordered by that health service last month.

The Morning Edition newsletter is your guide to the day’s most important and interesting stories, analysis and insights. Sign up here.