- the need for a detailed case review to be completed to provide clinical advice to assist the investigator;
- the time required to examine cases over a 10-year period and undertake a comprehensive clinical review;
- interruptions due to the pandemic; and
- the availability of investigators.
- strengthen a number of processes including supporting ongoing maintenance of endoscopy skills for staff;
- promote a transparent reporting and quality improvement culture;
- re-design credentialling committee documentation to better capture the outcomes of credentialling committee meetings;
- strengthen clinician performance appraisal processes where concerns have been identified;
- strengthen informed consent processes; and
- recommendations to improve consumer engagement.
- Reinforcing ‘speaking up for safety’ processes to ensure all staff know how to report concerns. Specific procedures and training have been put in place to ensure that all employees, regardless of their position, know how to report any concerns about clinical care.
- Introducing a dedicated patient safety officer position at Redland Hospital, which provides a further layer of incident review and compliance with reporting.
- A new governance structure for the Endoscopy Unit including a new dedicated Deputy Director of Endoscopy who reports through to the hospital’s Executive team and has strong connections with surgical colleagues across the health service.
- The introduction of standard endoscopy performance measures across the health service, including a quarterly report on each individual endoscopist, measuring their performance against peers and benchmarks.
- A dedicated, Metro South Health-wide team that performs audits on patient outcomes, including a specific audit on endoscopies.
- Improvements in consumer engagement including the addition of patient representatives on the hospital’s key governance meetings and the establishment of a separate consumer advisory group which seeks input and feedback on hospital operations and initiatives.
Metro South Health and Queensland Health are continuing to roll out a suite of initiatives in response to an investigation into care provided to a group of patients at Redland Hospital’s endoscopy services.
Queensland Health has today released a summary report and recommendations from the Part 9 health service investigation which focused on the standard of endoscopies performed by two doctors (identified as Surgeon 1 and Surgeon 2) and the clinical management of bowel-related procedures by Surgeon 1 between 2008 and 2018.
The report makes 37 recommendations addressing a range of clinical and operational matters identified during the investigation, all of which have been accepted.
Queensland Health also released its response to the recommendations, of which more than three-quarters have been implemented and the others under way.
The investigation, commissioned in May 2020, found 73 patients of the doctors received care that fell below clinically acceptable standards, with issues ranging from poor bowel preparation and lack of follow-up care to inadequate management of consent processes, and insufficient documentation of procedures.
While relevant care was provided to patients as part of the 2020 recall, Metro South Health will be in contact with affected patients and families.
Some of them have already had contact since 2020 but will be contacted again by Metro South Health. Metro South Health will ensure these conversations are conducted with care and compassion.
The doctors no longer work for Queensland Health.
Several factors contributed to the length of time for the investigation to be finalised including:
The report found several factors which contributed to the patients receiving care that was below the expected standard.
It has provided recommendations to:
The report acknowledges that during and since the period under review, Queensland Health and Metro South Health have instituted numerous system and safety improvements relevant to the circumstances leading to the investigation.
Queensland Health has led the establishment of a Gastrointestinal Endoscopic Quality Framework to monitor endoscopy standards and improve the system for monitoring histology results.
An expansion of Redland Hospital including six ICU and six high-dependency unit beds is underway and expected to open in 2025. This increases the range of services that can be provided safely at Redland Hospital.
Metro South Health has made significant improvements to its endoscopy services at Redland Hospital including:
Queensland Health has introduced a system-wide policy to strengthen and standardise how informed consent is obtained for procedures. Work is also underway on the procurement of a new information system to facilitate the electronic capture of informed consent.
Queensland Health has also finalised a pilot Patient Safety Net in four hospital and health services, which provides staff with a consistent, streamlined and transparent process for escalating a patient safety concern they feel has not been addressed through the standard reporting processes in a timely, proper or sufficient way. Patient Safety Net will be implemented in all health services during 2025.
The Summary and Recommendations from the Queensland Health Service Investigation Report and Queensland Health’s response are available on the Queensland Health website.