Select Committee on Chemotherapy Dosing Errors
The Hon. J.A. DARLEY (17:07): I am pleased to rise to speak to the report of the Select Committee on Chemotherapy Dosing Errors. The committee was established to inquire into the dosing errors which occurred at the Royal Adelaide Hospital and the Flinders Medical Centre in 2014 and 2015, with particular focus on what contributed to the error, the response from SA Health and the government, the suitability of SA Health's risk management and the impact this risk management had on affected patients.
Evidence heard by the committee really painted a bleak picture of the entire debacle. It was not only the fact that such a crucial mistake had been made, it was also the subsequent mishandling of the matter. The committee found that a mistake was made because proper protocols within SA Health were not followed. Not only were they not followed, it became clear to the committee that staff, including management, had little or no knowledge of the protocols. Clearly, there is room for improvement there.
Once the mistake had been identified, protocols to report the error were also not followed. As a result, underdosing continued for some patients. When patients were advised or discovered that they had not been receiving the correct dosage the manner in which they were treated is, quite frankly, appalling. No information was provided to them, nor were any notes made on their medical files that they were the victim of underdosing and would require more intensive medical monitoring.
Some patients were told via the media of how widespread the problem was, and others were forced to sign a gag order as part of receiving their compensation. This was incredibly insensitive, as comfort and support could have been found in other patients who were experiencing the same issues. Psychologically this would have been invaluable to patients during their time of need.
Patients overwhelmingly reported that SA Health's handling of the matter lacked empathy and sensitivity. The government seemed more concerned about covering themselves rather than what was best for the patients, patients that had already been through quite a traumatic event.
Patients gave evidence that they faced a fight throughout every step of the process. Even though the government had made public statements that the matter had been addressed, in reality, issues continued and it was often not until there was further scrutiny through the media that things got moving. This is clearly not what is needed at a time when a person is trying to fight cancer. The last thing they want is protracted argument with SA Health and the government over compensation, reimbursement of legal fees or even an apology. This is especially so given that they know their time with their family is limited and precious.
The committee has made a number of recommendations and, frankly, it cannot be difficult to improve on how this entire matter was dealt with. I only hope that the report will give some comfort to the victims and their families who have struggled long enough with this issue and provide impetus for the government to implement changes in line with the recommendations.