Investigations into botched surgeries at Caboolture Hospital inconclusive due to poor record keeping

The chair of the Metro North Health says no one will be sacked despite an inquiry into horrific allegations against Caboolture Hospital’s surgical and intensive care units finding it had failed to provide answers due to poor record keeping.

An inquiry into Caboolture Hospital has been unable to make an assessment on whether the services offered in its surgical and intensive care units are up to scratch because of poor record keeping.

The independent review, ordered in early September and handed down on Wednesday, was sparked after a Courier-Mail investigation revealed horror allegations at the hospital including; patients had been killed and maimed as a result of botched surgeries, surgeons were potentially performing operations they were not been trained in and a toxic workplace culture with widespread bullying and harassment.

While the report found no evidence that surgeons were operating outside their training, it was unable to adequately address the question of whether the standard of care at the hospital is appropriate.

Caboolture Hospital.

Key findings in the report revealed that Caboolture Hospital had more SAC 1 surgical incidents in 2020-2021 – self reported incidents that could lead to death or likely permanent harm – than any other hospital in Metro North.

The report made 19 recommendations, which included empathy training to address claims of a toxic culture, as well as providing training around clinical incident management, report writing, open disclosure, better auditing processes and responding better to patient complaints.

Metro North Health and Caboolture Hospital Board chair Jim McGowan said patients who complained to the hotline set up as part of the review would have their matters investigated and acknowledged that “a number of patients” were owed apologies.

“We will use complaints to try and improve the way we operate in the future,” he said.

However, he said no heads would roll because there was no evidence of malpractice by any one individual and that all recommendations made in the report would be acted upon.

Metro North Board Chair Jim McGowan. Picture: Richard Walker

The report also found there was a lack of engagement from clinical staff.

“Comments heard during the review indicated that poor leadership, lack of trust and transparency lead to poor morale and ineffective representation of concerns from clinicians in all areas of the multidisciplinary team,” the report said.

“The safety and quality reports provided by Metro North and Caboolture Hospitals do not adequately inform the reviewer about the safety and quality of services and care delivered by the Surgical and Intensive Care department at Caboolture Hospital,” the inquiry, led by eminent South Australian surgeon Dr Jim Sweeney, found.

“At Caboolture Hospital, the collation of key performance measures appears to be one person dependent and reliant on some bespoke health informatics systems that have evolved inconsistently across Metro North hospitals.

“The safety and quality data officer operates in isolation and may benefit from being part of a broader more holistic health informatics team using more mature and consistent health informatics reporting systems.”

The review backed up whistleblower claims that a poor workplace culture had led to widespread bullying and harassment.

“As a result of poor leadership, and fear of retribution because of past bullying and harassment, responses to staff surveys and suitable representation at meetings saw ineffective participation and inadequate information and feedback about safety and quality in particular,” the report states.

It also found evidence of racial and gender discrimination but said the incidents appeared to be isolated.

“Isolated incidents however are unacceptable, and the Administration needs to take further steps to ensure that this does not occur,” the report said.

One area listed as needing further investigation included “unplanned returns” to theatres with rates that “appear to be greater than other (Metro North) hospitals”.

CULTURE:

– Consider ways to educate and address the underlying culture issues prevalent throughout Caboolture Hospital including using empathy training, leadership mentoring, communication and give more opportunities for collaboration with multidisciplinary teams through attendance at safety and quality committee meetings.

SURGERY:

Caboolture Hospital to ensure a Caboolture Hospital surgical consultant is available using an on-call roster that is centrally accessible to all staff

– Encourage more multidisciplinary team members to attend the Morbidity and Mortality monthly meetings held, to identify achievements and opportunities for improvement related to

surgical outcomes and performance

– Establish a peer review process across the MNHHS Surgery and Intensive Care Stream of surgical complication cases and document actions for improvement.

PATIENT CARE AND SAFETY:

– review and restructure the Service Improvement Unit to provide contemporary support of safety and quality systems and reporting.

– Implementation of empathy training and improved patient communication/feedback for all staff at Caboolture Hospital to enhance patient and staff health literacy skills.

– Ensure that collated consumer feedback and experiences data and information is monitored and used by the Surgery and Intensive Care department to improve the safety and quality of services and care.