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General Purpose Standing Committee No. 2

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About this Item
Subjects -  Parliamentary Committees: New South Wales: General Purpose; Hospitals: Campbelltown; Hospitals: Camden
Speakers - Moyes Reverend the Hon Dr Gordon
Business - Committee, Report


    GENERAL PURPOSE STANDING COMMITTEE NO. 2
Page: 11274


    Report: Complaints Handling within NSW Health

    Debate resumed from 24 June.

    Reverend the Hon. Dr GORDON MOYES [5.53 p.m.]: It gives me great pleasure as Chairman of General Purpose Standing Committee No. 2 to present the report entitled "Complaints Handling within NSW Health". The report was published and presented to Parliament earlier as report No. 17 of June 2004. This was a highly publicised inquiry. It concerned the complaints handling procedure within New South Wales, in particular, the culture of learning and a willingness to share information about errors and failure of systems, and an assessment of whether the system encourages open and active discussion of improvements in clinical care.

    Honourable members would be aware of some of the events associated with the Campbelltown and Camden hospitals public relations issues concerning health care complaints handling. Committee members included me, as Chairman, the Hon. Patricia Forsythe, the Hon. Dr Arthur Chesterfield-Evans, the Hon. Amanda Fazio, the Hon. Peter Primrose, the Hon. Robyn Parker and the Hon. Christine Robertson. I might just say by way of appreciation to those members of the committee that we had a very difficult task. It was highly charged and emotional; it was constantly reported in the media—newspapers, television and radio. The media harassed many of those involved in making some of the 71 submissions and, consequently, it was a very difficult complaints handling presentation that we were required to make. I would point out, as I did in the Chairman's foreword in the report, that simply being an inpatient in an Australian acute care hospital is 40 times more dangerous than being in traffic and only 10 times safer than leaping out of an aircraft equipped with a parachute. In other words, we have the very serious likelihood of major failures in health care while, at the same time, having an unrealistic expectation of health care and error-free medicine.

    People go into hospital expecting to be healed or to come out better than when they went in. Unfortunately, very large numbers of people—and I will refer to the statistics on this a little later—do not face error-free medicine and many of them suffer adverse reactions. When permanent disability, or even death, results from time spent in hospital, we must learn how to handle that, learn from mistakes and put into practice systemic protocols to ensure that it does not happen in future. There are inherent risks in modern medicine and most people do not understand them. The inherent risks may mean not only miraculous cures but also adverse responses, such as permanent disability and even death. One of the most important factors in patient safety is being open about health care incidents and adverse events when they occur. This involves the whole question: How were the complaints handled? Unfortunately, evidence to our inquiry suggests we have a long way to go in developing a health care culture that is transparent about mistakes and is willing and able to learn from them.

    Unfortunately, many people believe there is a strong culture of blame and, in an era of litigation, people are not willing to admit mistakes for fear of litigation. I place on record the committee's appreciation to everyone who helped with the inquiry, particularly the 71 people who made submissions. Many of those submissions were extremely emotional because they involved dear ones who had died during procedures within the health care system. Indeed, many staff members suffered what they believed to be severe harassment. Although some good systems are in place to encourage reporting of adverse reactions, the present culture is an unwillingness to be open about and to learn from them. Cultural change is needed and, to that end, our committee made a total of 19 recommendations.

    I am pleased that the Minister for Health gave an open acceptance of those recommendations. The committee decided that, in the event of those recommendations not being put into practice by the current Minister for Health, it would reconvene on approximately 30 June next year to check progress within NSW Health and, if necessary, undertake further questioning.

    Given the nature of this inquiry, it is necessary for the committee's secretariat to liaise extensively with officers from NSW Health and the South West Sydney Area Health Service. On behalf of the committee I place on record the excellent work provided to the committee by the secretariat. I also acknowledge that the relatively newly appointed director-general, Ms Robyn Kruk, appeared before the committee on several occasions and was always forthcoming on the issues we raised with her. Health care is a complex issue, and we do not live in an error-free environment.

    I place on record the committee's appreciation of many staff, particularly those who have become known as the whistleblower nurses, who were the subject of much media scrutiny and, indeed, some harassment for their general bravery in coming forward and making clear what they were concerned about. I regard some people as being innocent in the whole procedure; somehow or other they got caught up in this issue. I make mention of Mr Ian Southwell, the Chief Executive Officer of South Western Sydney Area Health Service. His time in the job was terminated, yet no adverse findings were made against him. There may have been some knee-jerk reaction towards him.

    Honourable members will be aware that the number of key events relevant to both Camden and Campbelltown hospitals ran over a long period, and they received intense media scrutiny. Throughout 2003 there was intense media interest in the various allegations about inadequate patient care. That was not only the subject of further inquiries, such as the Health Care Complaints Commission undertaking, but also the subject of what became known as the Barraclough inquiry and the special commission of inquiry into the Campbelltown and Camden hospitals, known as the special commission. In all this, many people got caught up in a feeding frenzy.

    The inquiry that was established by General Purpose Standing Committee No. 2 was not intended to spend a great deal of time looking at specific incidents of what might be regarded as adverse reactions and poor responses towards staff and others who raised the issue. That was to be done by the Coroner and the special commission of inquiry. However, we were interested in looking at systemic issues relevant to complaints handling and seeing whether what was being revealed about the Campbelltown and Camden hospitals was typical of what was happening in other hospitals across the State.

    As a matter of fact, in submissions and in evidence we gleaned indications of the inability of many within the health care system to admit mistakes and errors, to learn from them, and to communicate well with people who are suffering because of them. We found this was a serious issue not only in these two hospitals but in many other hospitals. We had evidence that some hospitals—it is not my role today to go through the list of those hospitals—had a worse record of adverse patient events than those reported out of Camden and Campbelltown hospitals. On specific issues and allegations regarding the patients—

    Pursuant to standing orders debate interrupted.


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