Botched hospital stays caused more than 100 deaths

Three Victorian patients died or were seriously harmed after receiving surgery on the wrong part of their body last financial year.

Two others were left with life-threatening complications because foreign objects – such as surgical sponges, cotton swabs or clamps – were unintentionally left inside them at the end of an invasive procedure.

Sentinel events are incidents that lead to the death or serious harm of a patient in a hospital setting - such as a foreign object left in the body after major surgery. Credit: Getty Images

Thirteen people died or were seriously harmed because they were either given the wrong medication or incorrect dosage. And six died by suspected suicide in an acute psychiatric unit or ward.

The revelations are contained in Victoria’s latest annual review of hospital errors resulting in serious harm or death, otherwise known as “sentinel events”.

The report – compiled by government agency Safer Care Victoria and obtained by The Age before it was published – found there were 193 such incidents during the 2023-24 financial year, resulting in approximately 112 deaths.

While the overall number of sentinel events and subsequent deaths are down compared to last year’s record high of 245 incidents and 167 patient deaths, there has been a year-on-year spike in the number of suspected suicides in acute psychiatric settings and the proportion of sentinel events involving babies less than seven days old.

The six Victorians who died by suspected suicide in an acute psychiatric setting last financial year represent a threefold increase compared to 2022-23 when two individuals died in similar circumstances.

The proportion of self-harm incidents among uncategorised sentinel events also grew year-on-year, from 7 per cent to 10 per cent. The Age can confirm Safer Care Victoria will conduct a review of the way health services report these so-called “category 11” cases, which make up the vast majority of incidents.

In the meantime, Safer Care Victoria has recommended health services with acute psychiatric units or wards audit patient facilities and train staff on how to recognise when a patient’s mental health might be deteriorating.

The Age revealed late last year that the Allan government had backtracked on its promise to implement all recommendations from the Royal Commission into Victoria’s Mental Health System on time, missed several deadlines and rolled out a plan that changed the pace of its reforms.

During the 2022-23 financial year, 5 per cent of all sentinel events involved babies less than a week old. But this grew to 7 per cent last financial year.

Notifications from private health hospitals also increased by 43 per cent, but the report suggests this reflects better communication between private hospitals and the Department of Health and is not part of a concerning trend.

Safer Care Victoria chief executive Louise McKinlay said her organisation was dedicated to improving the state’s health system.

“The changes we are implementing will continue to strengthen the reporting culture of our health services, supporting continuous learning, so Victorians continue to receive the best care available.”

Health Minister Mary-Anne Thomas said hospital staff and government needed to learn from every adverse event.

“We’re ensuring our health services have the robust processes in place so that families and patients are supported, and our health services have greater clarity.”

If you or anyone you know needs mental health support, call Lifeline on 131 114 or Beyond Blue on 1300 224 636.

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