Victorian clinicians ignoring worried parents behind spike in harm and deaths

The Andrews government claims an almost sixfold increase in ‘sentinel’ events in the state’s health system since 2014-15 is due to increased reporting.

Victorian Health Minister Mary-Anne Thomas. Picture: NCA NewsWire / Nicki Connolly

Victorian clinicians ignoring concerned parents’ warnings about the worsening health of their children is contributing to a massive spike in preventable harm and deaths in the state’s hospital system.

The reported number of “sentinel” events has increased almost sixfold since the Andrews government came to power, reaching 240 in 2021-22 – including 38 events involving children – up from 168 events the previous year, and just 42 in 2014-15, in a trend the government claims is largely due to increased reporting.

Fronting the media to release a 2021-22 Safer Care Victoria report the opposition has accused her of sitting on for 14 months, Health Minister Mary-Anne Thomas on Monday announced a suite of measures aimed at preventing ­serious harm and deaths involving children.

“Deterioration of a child’s condition was the most significant factor contributing to paediatric sentinel events, and recognising and responding when patients, particularly children, are deteriorating, is a key theme of the report,” Ms Thomas said.

“No one knows a child as well as their parents, and we need to do better at listening to parents.”

A “sentinel event” is defined as a “wholly preventable incident ­resulting in serious physical or psychological harm to, or death of, a patient”.

The Safer Care Victoria report relates to 240 such events which occurred in the care of Victorian public or private hospitals, Ambulance Victoria, first aid or residential aged-care services in 2021-22.

They compare with 168 sentinel incidents in 2020-21, a previous spike of 197 in 2019-20, and just 42 and 47 respectively in 2014-15 and 2015-16.

Victorian Health Minister Mary-Anne Thomas and Premier Daniel Andrews. Picture: NCA NewsWire / Nicki Connolly

An increase of 72 events in 2016-17 to 122 in 2017-18 was at the time attributed to increased ­reporting resulting from the Andrews government’s establishment of Safer Care Victoria, which occurred in the wake of a spate of preventable child deaths at Casey Hospital, in Melbourne’s outer southeast, in 2016 and 2017.

The government has not ­revealed how many of the 240 most recently reported sentinel events were fatal, nor the exact nature of the “serious harm” caused in each case, citing patient confidentiality.

Speaking alongside Ms ­Thomas, senior paediatric adviser at Safer Care Victoria Ed Oakley, who is also chief of critical care at the Royal Children’s Hospital, ­argued the increase in reported sentinel events was “positive”.

“The reason Safer Care ­Victoria came into being was to improve the safety of the system, and to increase the transparency of harms that might happen in the system,” Professor Oakley said.

“The increased reporting is a sign that clinicians and health services have confidence in that transparency.

“We expect there will be further increases in reporting, which means that there’ll be better opportunities for us to learn and improve, so I think the families, parents and carers for all their ­efforts to making our system safer.”

Professor Oakley’s claim implies that hundreds of instances of preventable serious harm or death have gone unreported over previous years.

The new measures announced by the government on Monday include an “escalation system”, to be rolled out across the state to give parents and carers an alternative pathway to raise urgent concerns if they feel they are being ignored, and a 24-hour virtual paediatric consultation system to provide ­access to specialist paediatric ­experts and services to smaller health services which do not have them.

 

The government will also mandate the use of a standardised and age-specific chart whenever a child’s vital signs are recorded – to be known as “ViCTOR” or the Victorian Children’s Tool for ­Observation and Response.

Ms Thomas said the measures had been developed in close consultation with the families of children who had died or suffered significant harm as a result of sentinel events.

“These families are determined that no parent has to experience the pain that they have suffered,” Ms Thomas said.

“To those families who are impacted by today’s report, you knew your children best. You knew when they were not OK, and your concerns were not properly escalated. This is not OK.

“I’m so sorry that this has happened to you and to your families. We will never be able to make right what has happened. But we are determined to make sure that it never happens again.”

Opposition health spokeswoman Georgie Crozier said if the government was genuine about increasing transparency, it would have released the report sooner.

“This is another example of the government cover-up and spin, and I think Victorians are fed up,” Ms Crozier said.

“(The government) do not hold this issue seriously.

“If they did, this report would have been released months ago when it was due. It’s 14 months overdue.

“Children are dying, Victorians are dying, because the health system is broken. What the government isn’t telling you is how many Victorians have tragically died because of the Andrews government mismanagement, neglect and funding cuts.”