Incidents in the South Australian health system are being subjected to secret inquiries beyond the reach of the coroner’s court, the state’s Opposition says.
Andrew Knox is one of 10 people whose chemotherapy treatment was botched at the Royal Adelaide Hospital (RAH) and Flinders Hospital, when he received half the necessary dose.
“I’m trying to keep myself as fit as I can,” Mr Knox said.
“Good food and good exercise, that’s about all I can do and hope that I defeat the clock.”
Mr Knox still questions the department’s version of events, particularly what is in his records, but the quality of the investigation is not in dispute.
The Government’s own report said “the level of investigation required wasn’t undertaken”.
And despite a departmental request, the RAH “did not conduct a root cause analysis investigation”.
“If there had been a root cause analysis they would have known back in February last year, 2015, that I’d been under-dosed unnecessarily instead of waiting to be gobsmacked by the information coming from the media on 5th August 2015, six months later,” Mr Knox said.
Root cause analysis or RCAs started in the 1950s when NASA wanted to investigate failures with rockets.
They are enshrined in the Health Act, designed to get to the bottom of complex incidents.
But Opposition spokesperson Stephen Wade said RCAs were secret by law, and not even the coroner could discover their recommendations or deliberations.
“To think that a court of the state which has a particular responsibility to protect South Australians from the potential for a repeat of a death is not able to get all of the information it might need to do its job I think is very concerning,” Mr Wade said.
Health professionals ‘more protected than police informers’
Coroner Mark Johns said the protection surrounding RCAs meant health professionals received greater protection than police informers.
“I can’t understand why it’s necessary to obtain a frank account of something, to offer secrecy,” Mr Johns said.
“There is no similar protection in that situation for a police informer.
“It is an accurate reflection of the law of the state and it is a bother to me because it’s impossible in such a situation to be able to test what a witness is saying before the court with what they’ve said in this previous secret environment.”
Mr Johns said there was evidence from private hospitals that potential coronial cases had gone un-notified because they had been through an RCA.
But the Health Department’s Di Lawrence said that did not happen in the public system.
She said the secrecy was necessary to get to the truth.
“The reason for [the secrecy] is to promote a positive safety culture so people can speak openly and not fear being crucified or criticised … in a coroner’s court,” Ms Lawrence said.
“And currently because it is protected we have a culture where people ring us up and talk to us very often about things that haven’t gone as they should so it’s actually working well.”
Mr Knox disagreed.
“For a coroner to be barred from delving into the senior medical fraternity is beyond explanation,” he said.