INQUIRY INTO OBSTETRIC

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(No Transcript)
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INQUIRY INTO OBSTETRIC GYNAECOLOGICAL
SERVICES AT KING EDWARD MEMORIAL HOSPITAL
1990-2000
NEIL DOUGLAS
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• KEMH
• Tertiary obstetric and gynaecology hospital
• 250 beds
• 5,000 births / year
• 5,000 gynaecological operations / year

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Child Glover report

• adverse events - especially after hours
• no reporting/monitoring system for adverse events
• lack of clinical accountability
• junior doctors feeling incompetent calling senior
  doctors for help
• senior doctors delay in attending when called
• little evidence of peer review - bashing up the
  juniors
• little supervision of junior doctors - perception
  that midwives and registrars run the hospital
• no evidence of a formal credentialling process

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Response

• 1. claim that findings were allegations
• 2. claim that denial of natural justice
• 3. Supreme Court action

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• KEMH Inquiry
• Clinical members
• Professor Jeffrey Robinson
• Dr Kathleen Fahy

• Initial terms of reference
• very wide
  whether incidence of adverse
  clinical outcomes 1990-2000 was acceptable
• Interim report (August 2000)

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Amended terms of reference

• 1. what, and how, services were provided at KEMH,
  1990-2000
• 2. identify any deficiencies
• 3. recommend changes

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Choice re focus

• 1. Particular incidents and individuals
  - what happened?
  -
  who is to blame?
  OR
  
  2. Systems and
  organisational issues
  - nature and extent of system problems
  - how to improve delivery of
  services

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Methodology

• 1. Clinical file review - 605 cases
• 2. Selected issues analysis
• 3. Comparative data analysis

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Key selected issues

• 1. clinical practice
• 2. clinical policies and guidelines
• 3. incident reporting and management
• 4. education and training of clinical staff
• 5. employment issues affecting clinical staff
• 6. quality improvement.

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Evidentiary material

• 1,600 KEMH patient clinical files
• 293 written submissions
• interviews with 70 patients
• evidence from 106 staff members
• consultants reports
• other documents - 2.25 million pages

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Inquirys report

• (www.slp.wa.gov.au)
• 5 volumes 2,500 pages
• no formal findings
• 237 recommendations

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Cultural barriers to change

• 1. Reluctance to admit errors and flaws.
• 2. Reluctance to adopt a beyond blame
  culture.
• 3. Reluctance to acknowledge that clinicians
  are accountable.

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1. Reluctance to admit errors and flaws

• review of 372 high risk obstetric cases
• 47 - one or more clinical errors

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Clinical errors

• Error Type
• 1. Failure to recognise a serious and
• unstable condition 20.4
• 2. Inappropriate omission (not CTG) 20.2
• 3. Inappropriate intervention (not CTG) 16.7
• 4. Incorrect action in relation to CTG 13.7
• 5. Failure by senior staff, after being
  notified, 13.4
• to assess a woman/baby in a serious
• and unstable condition

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Level of most senior clinician providing care at
the most crucial times

• Clinician of cases
• Junior doctor or midwife 70
• Senior registrar 9
• Consultant 21

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Error Rates

• Clinician At least More than
  1 error 3 errors
• Resident 76 27
• Registrar, Levels 1- 2 65 15
• Midwife 60 10
• Registrar, Levels 4 - 5 40 9
• Registrar, Levels 5 - 6 34 0
• Consultant 28 3
  

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1. Reluctance to admit errors

• Leape (1994)
• concept of infallibility
• pressure to intellectual dishonesty
• (a) conceal mistakes
• (b) shift blame

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KEMH responses to an identified problem

• ignore
• deny
• criticise messenger
• blame others (e.g. bash juniors)
• refuse to acknowledge underlying causes
• refer to a committee
• unique

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AMA (WA) response to KEMH Inquiry

• 1. the Inquiry should be scrapped
  
  (22 September 2000)
• 2. the Inquiry was a waste of taxpayers
  money (24 October 2000)
• 3. the Inquiry was by any measure a farce
  (1 November 2000)
• 4. the Inquirys findings should be made to
  a university anthropology unit because they
  would be outdated and totally irrelevant
  
  (19 May 2001)
• 5. threat of Supreme Court action (27
  November 2001)
• 6. claims of denial of natural justice
  (28 January 2002)

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AMA (WA) transformation

• ' the 237 recommendations regarding clinical,
  administrative and management issues have
  significant implications, not just for KEMH
  itself but for the health system in general.

The AMA would urge all practitioners,
particularly those in management roles to
familiarise themselves with the report's
executive summary and recommendations that are
available on the Internet '.
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2. Reluctance to adopt abeyond blame culture

• Perinatal Mortality Committee meetings
• witch hunts
• finger pointing exercises
• blame culture
• intimidating
• denigrating
• vindictive

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3. Reluctance to acknowledge that clinicians are
accountable

• peering in from outside
• incident reporting and management

• Doctors Alert
• 1. no patient information to management
  without written authority from the patient
• 2. no answers to management questions without
  prior written notice of question.

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Management

• 1. Significance of management
• management is crucial to delivery of health care
  
• management affects all aspects of the quality
  of health care.
• 2. Who should manage?
• the best doctors are not necessarily the best
  managers
• the best managers are not necessarily
  doctors
• doctors cant be in two places and do two
  jobs at the same time.

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Conclusions

• delivery of health care can, and should be
  better
• cultural and management barriers

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