‘We are really on the edge’: WCH doctors speak out

Resources at the Women’s and Children’s Hospital are “so thin on the ground now that we are seeing errors”, doctors’ incident safety reports are being downgraded and staff have serious reservations about planning for the new hospital, frontline medicos have told a parliamentary committee.

Apr 06, 2021, updated Apr 06, 2021
Photo: Tony Lewis/InDaily

Photo: Tony Lewis/InDaily

The evidence of four doctors who expressed serious fears about patient safety and future planning was given in a confidential hearing in February, but has been made public today with their approval.

Their litany of concerns revealed to the Select Committee on Health Services in South Australia include:

  • Tired and fatigued doctors “are at risk of error and potential harm”
  • Doctors’ safety reports are being downgraded
  • The new Women’s and Children’s Hospital (WCH) is going to be too small and lack facilities
  • There are only 12 intensive care beds planned for the new WCH – one less than exists in the current hospital
  • There is a significant lack of medical equipment at the WCH
  • Frontline staff are pressured not to speak out about problems
  • A lack of advanced training positions is compromising the standard of service delivery
  • Two of four baby deaths linked to a lack of heart surgery services could potentially have been preventable

The evidence was given by infectious diseases department head Celia Cooper, paediatric intensive care unit senior consultant Steve Keeley, staff specialist Brett Ritchie and staff specialist Nan Vasilunas.

Ritchie told the committee “I am here today because, as a paediatrician, I feel that I need to advocate for the women and children of this state, and that probably overrides everything else”.

“At the heart of the problem, really, has been a successive failure to adequately resource the increasing demands to make sure that we can provide very high-quality care and, in particular, reduce the risk to our patients as we progress forward,” he said.

“This requires sufficient doctors. It requires sufficient equipment. It requires the appropriate training, research and education to make sure what we do every day can be improved upon.

“We’ve got people working at the sort of extremes, doing absolutely everything they can.

“As clinicians, the thing that really alarms us is that the relationship between risk to patient and human error is there every day in our work.

“When we are tired and when we are fatigued and when we are overburdened and when we are burnt out, we know that we are at risk of error and potential harm.”

Ritchie said “people who aren’t clinicians don’t get that, and it really hasn’t been able to cut through”.

“So, from that clinical perspective, we feel we are really on the edge here,” he said.

“What more does it take before something will change?”

He said that since a group of more than 200 doctors raised their concerns with management in 2019, “effectively nothing has changed and we are still carrying this burden”.

“We don’t know what to do with it,” he said.

“We have exhausted all the avenues, and I think we also feel the community need to be alerted to really what’s going on here because we don’t know where to go.”

Doctor safety reports are being downgraded

Ritchie said “we are at the point where things are so thin on the ground now that we are seeing errors”.

“We have risk registries that are supposed to record these risks,” he said.

“We even know that the rating of the risks is being changed, so clinicians will put in a concern about a risk and it is being modified. Usually the modification means stepping it down in terms of its severity, not tweaking it up. This is the system we are dealing with. We’ve got no way of alerting people in a reliable way because the whole thing has just been manipulated.”

Lack of resources

Paediatric intensive care doctor Steve Keeley, who has worked at the hospital since 1990, said “increasingly there is a gap developing between what we can provide to the families, the children and women of South Australia and what is provided interstate”.

He raised the recent controversy around a lack of paediatric heart surgery services in SA, which doctors last year said contributed to the deaths of four babies.

“You might be aware of the recent furore over cardiac surgery as an example of an attempt to try to redress an increasing gap and a huge problem for some of the families of South Australia, but there are other conditions of a very similar severity where families have to go interstate for that care,” he said.

The committee was later told those conditions include bone marrow transplantation and solid organ transplantation.

“Increasingly, these conditions are becoming standard treatments that should be able to be provided everywhere, yet we don’t seem to have the aspiration amongst our senior executives, our board, even the politicians who obviously have to fund it, to try to redress some of those gaps,” Keeley said.

“Increasingly there is this cognitive dissonance that we’re suffering under, where we’re constantly being advised or told that we want a world-class facility, that we want to be world-class, but we’re not funding for world-class.

“We’re not even funding for standard Australian care that is available in every other state.

“Increasingly, that is becoming a frustration.”

Keeley said there was “not a departmental head at the Women’s and Children’s that will not have equipment and resource deficiencies, staffing deficiencies, nurse educator deficiencies, allied health deficiencies”.

“They know if they could redress that, it would improve the care that they are providing,” he said.

Concerns new hospital won’t have enough beds

Keeley said what was even more concerning was the lack of planning to fix these problems at the new hospital.

“There is not anyone I have spoken to who does not believe the site is too small—not one doctor,” he said.

“The evidence is clear.

I work in the paediatric intensive care unit and we have 13 beds; the plan for the new building is to have 12 paediatric intensive care unit beds. Can you believe that?

“Perth Children’s went from 10 beds to 20 in their new build. They increased the total number of beds in the new children’s hospital in Perth; we are decreasing the number of beds.

“It’s almost unfathomable to us that these sorts of decisions can be made despite the technical experts, the doctors that are advising, the planners and, yes, of course, Treasury, the payers—yet decisions are being made without any clinician input whatsoever.

“No-one believes that in a future hospital like this that has to serve the families and children of South Australia for 20 to 30 years that the bed numbers are sufficient. I guess even our executive, I think, have come to that conclusion.”

Keeley believes that rather than fixing current issues “the new building will exacerbate problems”.

He said his concern was based on “a number of my own experiences in attending the user group meetings where very simple questions could not be answered”.

“For instance, there’s a concept called the ‘hot floor’… the ‘hot floor’ is where the operating theatres are,” he said.

“Typically, because half our patients in ICU come from theatres, ICU is on the same floor. Typically, neonatology is on the same floor, and also the delivery suite is on the same floor, because if you need an emergency caesarean section and you have to go to the operating theatre for it you don’t want to be going up a lift and across the corridor to get access—time is of the essence.

“I have asked a very simple question: can all those things fit on the same floor? I haven’t got an answer. They say, ‘We haven’t done the blocking and stacking yet.’

“When I asked a simple question about, ‘Well, why 12 beds for the paediatric ICU, and what about the high dependency unit patients?’ ‘Oh, we haven’t resolved what to do with the high dependency unit patients yet,’ was the response.”

Keeley said he also asked about plans for a “simulation suite” at the new hospital, to help train new doctors “in skill development, aid in crisis management and problem solving under stress”.

“Simulation suites are the standard in every other hospital,” he said.

“The Royal Adelaide Hospital has one and the new Perth Children’s Hospital has a simulation suite. I asked the question, ‘Where is it?’ No-one can answer. I don’t think they have even thought about putting in a simulation suite in the new hospital. That’s the level of thought and the lack of coordination.”

Lack of medical succession planning

Vasilunas told the committee that “medical succession planning is a significant and ongoing concern”.

“The lack of advanced training positions, both senior registrars and fellows, at the Women’s and Children’s Hospital compared with other local and interstate hospitals is compromising our ability to achieve a consistently high standard of service delivery,” Vasilunas said.

“It’s blocking career development and it’s sending high-quality trainees interstate and jeopardising the future medical consultant workforce who are providing care to the women and children of South Australia.”

Doctors pressured not to speak out

Ritchie told the committee doctors were pressured by management not to speak out.

“I think the concern is if people speak up it might go against them personally, professionally and perhaps even go against them in a negative way for their unit,” he said.

“So they shut up, they keep their head down and they don’t rock the boat.”

“You are under this constant sort of pressure to really give the impression that everything is okay at the Women’s and Children’s Hospital and that things aren’t bad, because if you let the community know that we are having problems, they are going to lose trust in the whole system.

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“Probably one of the most disheartening things is that our board doesn’t acknowledge the extent and the depth of the problem.”

Ritchie said it had been “really hard for all of us to stand up” and speak out.

Keeley added he too had “felt the pressure… not to air our dirty laundry in public; that is a bad look”.

“I have spent my entire career as a full-time salaried doctor in the public health system,” he said.

“I have enjoyed enormously my time at the Women’s and Children’s. I don’t want people to think that it’s a basket case. I want people to think it’s an excellent hospital but that it could be better, and it should be better.”

Equipment shortages

Keeley said there was a $12 million equipment list “still unfunded” at the hospital.

“Simple things like that—just purchasing another piece of equipment—have yet to be done and don’t look as if they are going to be done, so what else can you do?” he said.

“In the end you have to either stay quiet or speak up, and when you speak up, of course, there is this general feeling that perhaps the community as a whole is losing a bit of faith in the place, and none of us want that, but I think that is a pressure that we still feel.”

Ritchie said at a recent meeting he was told “we need to be careful about the brand of the WCH, by us speaking out”.

So what does that say really, when we (are) more worried about the impression of the WCH and the brand than they are about providing the necessary staff, equipment, training on the ground?.

“It just really frustrates me and I get really angry. We struggle with this every day.”

Vasilunas said junior doctors in particular felt compelled to keep quiet about problems.

“I think there is a level of intimidation in speaking out, in terms of career progression, particularly for the junior trainees who… will never speak out,” Vasilunas said.

“In fact, they have made it quite clear to us that they are unable to because the same people who interview them, on their interview panel, are the ones who they complain to about their rosters, who they speak out to about work conditions, etc., so they literally cannot complain because they are worried that they then won’t get rehired.

“They are on yearly contracts so there’s really no job security for them. That’s why I wanted to take this stance today, because they really cannot be heard.”

Lack of infection control planning

Cooper told the committee that “the importance of infection control” raised by the COVID pandemic had not been adequately addressed in planning for the new hospital, particularly with bed numbers.

“What they call the footprint of the hospital—that’s the actual area that’s available for the hospital in terms of a single floor—I think is going to be quite challenging from a pandemic point of view because rooms need to be large,” Cooper said.

“There needs to be space given for ventilation systems and I think it’s going to make it challenging. A very thin tall building, even though it may have the same area in square metreage as a wide shorter building, functionally is not the same at all…”

Four baby deaths

Committee chairperson SA Best MLC Connie Bonaros asked the doctors about the deaths of the four babies last year linked to a lack of heart surgery services in SA and whether “any of those babies could have potentially survived had we had the service available here in South Australia”.

Keeley said there was “absolutely one baby who may have survived” had services been available locally.

“My view is that another baby died, again, because our system of care isn’t geared around providing cardiac surgery for children—it’s stabilising patients and transferring them (interstate),” he said.

“I’m a paediatric intensivist. I have a specific view and my view is that we didn’t do well by that baby, so I think at least two of them (could potentially have survived).”

Keeley also said those involved in preparing a report about the deaths of the four babies “didn’t speak to any of us involved in the care of these children”.

In a statement, a spokesperson for the Women’s and Children’s Health Network said “we are committed to delivering the highest level of care to our patients, and in order to do so, the wellbeing of our staff remains a priority”.

“We support our staff to raise concerns, and are always willing to have open discussions around any issues,” the spokesperson said.

“We take any concerns very seriously, and we work closely with our staff to ensure they have the support they need.

“The quality of the services we provide is our number one priority and families should rest assured that our patients will always have access to the treatment they need.”

The spokesperson said work was underway on a $50 million upgrade to the current hospital “to ensure we continue to have the most modern facilities possible as we plan our journey to the new Women’s and Children’s Hospital (WCH)”.

“Building a new hospital is a challenging and exciting process, and that’s why we’re working closely with our clinicians, staff and consumers during the planning, design and delivery phases of the project,” the spokesperson said.

“Consultation continues on the new hospital. There has already been more than 1,000 hours of consultation with close to 700 doctors, medical, nursing/midwifery, allied health and other staff, as well as 35 consumers.

“Our staff will continue to play a vital role in shaping the new facility in order to deliver the best possible services to our patients and their families.”

Regarding concerns about a lack of heart surgery services, the spokesperson said: “We continue to work with our clinicians to implement a paediatric Extracorporeal Membrane Oxygenation (ECMO) service at WCH.”

Health Minister Stephen Wade said “we take the concerns of clinicians and staff at our hospitals very seriously”.

“Consultation on the planning for the new Women’s and Children’s Hospital remains open and we have invested heavily in the consultation process ($600,000) to ensure we engage a wide group of people,” he said.

“This includes 93 Project User Groups to support consultation so that we ensure that clinicians and other stakeholders have significant input in the design of the new hospital.”

In response to concerns that doctors’ safety incident reports were being downgraded, Wade said the government had last year commissioned an “independent review of the Safety Learning System”.

“The review made 31 recommendations, which includes five regarding the classification of incidents,” he said.

“SA Health have accepted all of the recommendations and have established a reference group to oversee their implementation.”

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