Qld hospital death caused by mismanagement
A preventable death was caused by clinical mismanagement at Caboolture Hospital and a "negative workplace culture" has potentially compromised the safety and quality of care, an inquiry has found.
Metro North Hospital and Health Service ordered a review in early September after media reports and Queensland's Liberal National Party aired claims of preventable deaths, surgical negligence and a culture of bullying at the facility north of Brisbane.
The inquiry, headed by Dr James Sweeney from St Andrews Hospital in Adelaide, looked at the allegations about the hospital between 2015 and 2020.
The final report, handed down on Wednesday, found one of the 37 deaths after surgery reviewed could be attributed to clinical negligence.
"Assessors identified only one preventable clinical management issue 'decision to operate' that caused the death of a patient who otherwise would have been expected to survive," the report said.
It said 21 deaths didn't meet the criteria for review, while 15 cases had been admitted as emergencies with life-threatening conditions.
Three may have benefitted from intensive care, two were unplanned admissions to ICU, two involved delays in confirming surgical diagnoses and there was one case where fluid balance could have been better.
"None of these cases were identified as preventable," the report said.
Addressing the report on Wednesday, Metro North Board Chair Jim McGowan said "no heads were rolling, because there was no evidence of any malpractice".
"There are accidents that occur in hospitals every day. Surgery is a complex issue," he told reporters.
"There are 5000 operations in Caboolture a year, and the number of people who are affected is relatively small, but each one is important."
A number of patients had received apologies, and Mr McGowan said the hospital needed to make sure it was working with people so they "get a satisfactory outcome" when something goes wrong.
The report also noted 31 unplanned theatre returns after surgery, which is greater than other Metro North hospitals.
About 30 per cent were for post-operative bleeding, but the panel said the 31 theatre returns made up 0.006 per cent of 4894 operations performed between 2020 and 2021.
"In the categories of surgical complications and health care associated infections, Caboolture Hospital was the second-best performing hospital out of its peer group of 20 hospitals," the report said.
A review of the scope of surgeons also found no individuals had practiced outside their area at the hospital.
However, a "negative workplace culture and destabilised governance structure" at the facility which could put patient safety at risk, the report said.
"The management structure at Caboolture has had some changes which are now imminent and we will be recruiting new people into some of those critical roles," Mr McGowan said.
Some staff didn't understand their roles, the panel wrote, and "personal and professional boundaries" affected their judgment.
"There appeared to be a degree of passivity about difficult personnel issues, with clinicians not vigorously pursuing with management any concerns they may have, nor listening to the concerns of others," the report said.
"It became clear that clinicians in leadership roles paid insufficient attention to the risks in relation to quality of service delivery because of their lack of responsibility and focus within roles."
Poor leadership, past bullying and harassment and a lack of trust and transparency, the report said, lead to low morale and ineffective communication of concerns by clinicians.
The report noted that in that workplace culture, feedback on safety and quality concerns in staff surveys and meetings was inadequate.
The panel has made 19 recommendations to improve processes and the workplace culture at the hospital.
