Back to punishment in New South WalesBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7474.1111 (Published 04 November 2004) Cite this as: BMJ 2004;329:1111
New South Wales in Australia appears to be reverting to its origins as a penal colony, if the interim recommendations of the special commission of inquiry into Campbelltown and Camden Hospitals are any guide.
The hospitals, on the southwestern outskirts of Sydney, serve a population of 800 000 people. In November 2002 four nurses made 71 allegations to the then state health minister, Craig Knowles, about “unsafe” care of patients in the hospitals. The allegations were referred to the Health Care Complaints Commission and were investigated. The commission's report of December 2003 focused on the systemic problems underpinning many of the adverse events, particularly under-resourcing and under-staffing. The report's accounts of individual cases will be familiar to any doctor working in a modern hospital, describing clinical errors of judgment, fumbled handovers, delays in treatment, and poor communication.
Nurses have been spat at
The government was incensed that blame had been laid at its feet. The complaints commissioner was sacked, and a senior member of the New South Wales bar, Bret Walker, was appointed to head a special commission of inquiry. His approach, detailed in two interim reports, was to recommend reinvestigation with a view to disciplinary action against individual doctors and nurses, almost 30 of whom have been referred back to a revamped complaints commission. None of these doctors or nurses has yet had an opportunity to present their version of events. Meanwhile, an investigative television programme raised serious questions about the backgrounds and motivations of the four whistleblowers.
The government's response and Mr Walker's approach have dismayed people engaged in efforts to improve the safety of patients. Paradoxically it was Mr Knowles who initiated these efforts when he set up the Institute for Clinical Excellence in 2001, an independent statutory authority, charged with improving patient safety. It has trained more than 2000 senior clinicians and health managers in root cause analysis (RCA) of adverse events. Many system vulnerabilities have been identified and corrected as a result of RCA.
These successes have now been jeopardised. The initial inquiry triggered sensational newspaper headlines and aroused widespread distrust of the state's public hospital system. Staff at the hospitals involved are severely demoralised, and anger in the community has been so intense that nurses walking in uniform down Campbelltown's main street have been spat at. Patient safety managers throughout the state report reluctance on the part of clinicians to be involved in RCAs for fear that they may become embroiled in Walker-style inquiries. Concern about possible criticism by relatives has led to a state-wide reluctance to discharge patients from hospital, partly because a number of the complaints concerned patients who died after leaving Campbelltown Hospital. This has aggravated the already serious problem of blocked access.
Mr Walker reacted angrily to criticism of his first interim report and has rejected the notion that a successful systems approach is incompatible with widespread punishment. He has repeatedly emphasised the need for individual accountability of doctors and nurses. However, almost all the incidents complained of did not involve egregiously culpable behaviour, such as drunkenness or deliberately unsafe acts, but resulted from clinical errors in which three closely related elements—the doctor's actions, the patient's illness, and the system—have yet to be unravelled before an assessment can be made about any individual culpability. If this is done it should be possible to apply a decision tree of the type described by James Reason in Managing the Risks of Organisational Accidents to determine culpability, if any. It is unfortunate that doctors and nurses have been subjected to punitive sanctions before this process was applied.
The need to separate the tangled elements of a clinical event means that complaints about a doctor or a nurse require different handling from complaints about other professionals. Mr Walker rejected this (www.lawlink.nsw.gov.au/special_commission): “I really don't have any patience with this idea that a complaints system for doctors should be different from a complaints system for anybody else, and that doctors mustn't suffer the equivalent of a court martial.”
Mr Walker eventually acknowledged in his final report the value of a systems approach. However, it was made clear that the interim reports are not provisional and that the disciplinary recommendations will not be reversed. They therefore remain as a lamentable case study of an inappropriately punitive response to adverse events. The operation of the state's hospital system has been impaired, and there are ill omens for the future improvement of patient safety. As James Reason has pointed out, communities generally get the disasters they deserve.
Competing interests TBH is a faculty member of the Institute for Clinical Excellence, Sydney, and a director of MDA National Insurance, an Australian medical indemnity company. At the time of writing no member of MDA National was the subject of a complaint relating to Campbelltown or Camden Hospitals.