SafeWork SOS: Inquiry call over RAH emergency department

EXCLUSIVE | SafeWork SA has been asked to investigate conditions inside the Royal Adelaide Hospital after snap inspections of the crowded emergency department discovered “clinical risk”, distressed staff and patients, and clinicians at “breaking point”, confidential documents obtained by InDaily reveal.

Apr 15, 2021, updated Apr 15, 2021
Photo: AAP/David Mariuz

Photo: AAP/David Mariuz

The doctors’ union has written to the workplace watchdog alleging contraventions of the Work, Health and Safety Act, after witnessing “significant overcrowding” in the city’s ED during two inspections last month, “causing immediate and significant distress and anxiety to both clinicians and patients”.

SafeWork SA has confirmed “inspectors have been allocated to these matters”.

Copies of confidential inspection reports and letters from the doctors’ union to SafeWork SA have been obtained by InDaily after they were distributed to doctors working at the RAH ED and within Central Adelaide Local Health Network Mental Health.

The reports are secret because they include internal emails and documents obtained during the inspections, which detail repeated warnings over weeks from multiple insiders to SA Health executives about ongoing capacity problems – particularly around mental health patients.

In the documents, SA Salaried Medical Officers Association chief industrial officer Bernadette Mulholland tells SafeWork SA that she conducted a snap inspection of the RAH ED on March 14 after being contacted by concerned doctors.

It followed another inspection only a fortnight earlier on March 1, which raised similar alarm bells.

In her report to SafeWork SA, Mullholland says she was advised there were 18 mental health patients in the ED, with one waiting 69 hours for a bed, while another 37 emergency patients were also waiting for a bed.

She states “demoralised” doctors told her there was “significant anger and frustration toward the hospital and the Department of Health given this matter continued to be a problem without any resolution”.

She was told that “clinical functioning of the ED was made difficult because of the bed block and long-stay patients in the ED”.

“(I) was advised there was significant ‘clinical risk’ and it was difficult to identify the governance in the organisation,” Mulholland told SafeWork SA.

“The medical officer stated the ‘accountability and responsibility is dispersed and difficult to understand’.”

Mulholland was told that things were likely to get worse as winter progressed.

She said that on the night of March 14, the ED had been reduced to effectively half capacity because the “east wing was now being managed to care for the mental health patients and patients waiting for a bed, and only the west wing of the ED was available for presenting patients”.

Her safety inspection report reveals the hospital had been ramping ambulance arrivals “on and off since 3am (as) there was no space left within the RAH”, with additional mental health patients being housed at the Adelaide Clinic.

She said the prevalence of long-stay mental health patients in the ED was “distressing for the patient”, as well as for the ED and its staff.

“Many of the clinicians were at ‘breaking point’,” she reported.

She was advised “a couple of the mental health patients were wandering around the ED as they felt confined in small cubicles”.

She also counted 10 security guards in the ED, which “only reinforced to clinicians and patients the environment was unsafe”.

This is a human rights issue

In a letter sent to doctors yesterday containing her reports, Mulholland asks them to “help SASMOA investigate and try to improve RAH ED work health and safety problems”.

“RAH ED resources and procedures are grossly inadequate to safely deal with the level of patient demand, making the RAH ED dangerous for patients and clinicians,” she tells them.

An attached letter to SASMOA from a Central Adelaide Local Health Network executive details that there were in fact five rostered guards that night, between 11 and 16 “patient-minding guards” and a further four “roving guards”, along with a shift supervisor not rostered to the ED “but available to respond to events”.

“This is a human rights issue which (I) would expect SafeWork SA would have legal obligation to action, together with the Department of Health and Wellbeing, the Office of the Chief Psychiatrist, the Health and Community Services Complaints Commissioner and the Mental Health Commissioner,” Mulholland wrote to SafeWork SA.

She detailed several perceived breaches of the Act, including a failure to implement “any appropriate or reasonable response to eliminate or remove known risk to health, safety and welfare of the workers at the site and patients seeking health care”.

SASMOA is requesting SafeWork conducts a “complete and independent review” into the issues raised “before further adverse outcomes result to staff and patients in this site”.

The CALHN response said on the night in question, March 14, there were 261 total presentations to the ED, 15 of whom “had mental health as the presenting problem”, with an average length of stay of 5.1 hours.

Of those, seven patients remained in the ED for two days or more – all of them mental health patients, who presented with a range of “agitation/delusions”, “situational crisis”, “depression” and “violent behaviour”.

When InDaily contacted Mulholland about her inspection reports and the confidential SA Health documents, she said she had an obligation to ask SafeWork SA to investigate “given the unsafe work environment that I viewed in the ED and the long-stay mental health patients that I viewed”.

“It’s been very clear on both occasions that we don’t have the resources available to assist in providing the necessary clinical response in a timely manner for those mental health patients,” she said.

Mulholland said it was obvious from viewing the internal SA Health documents that there was a high level of concern from the hospital administrators and doctors on the ground about the escalating conditions.

“It’s quite clear from viewing the documents that the Royal Adelaide Hospital administrators are wanting to find a solution to the issue,” she said.

“It would appear that the emails express some frustration in the department that this is not happening.”

She believed SA Health executives were “too far removed on a day-to-day basis from the hospital’s operations – what happens to our patients and clinicians”.

“Therefore they’re not providing the resources necessary to help our patients and the community,” she said.

In several emails, the mental health boss of CALHN, Professor John Mendoza – who has since quit in protest at a lack of action – gives updates on ballooning patient numbers and outlines a “crisis in mental health” including problems with forensic patients, who should be in a specialist facility, taking up beds and “overwhelming our capacity”.

InDaily reported on this long-standing problem yesterday.

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“This is getting into clinically dangerous territory,” Mendoza warns in emails sent to SA Health executives and the Chief Psychiatrist, John Brayley.

“This is extremely distressing and harmful for all concerned.”

He wasn’t the only one sounding the alarm.

In one email about forensic patients, CALHN mental health clinical program lead nurse Lesley Legg says “we have again 24 in RAH ED” and “we have had 22-plus every day”.

“We have six patients waiting (for specialist forensic facility) James Nash House and no beds until next week,” she says.

“We urgently are requesting assistance from the forensic services to place these consumers.”

In another email, RAH emergency doctor Patrick Feeny says he “just wanted to record the state of the ED this morning; as well as a lack of beds across the board”.

He writes there were 25 mental health patients waiting for beds, including four waiting more than 60 hours, four more than 40 hours, four more than 30 hours and six more than 24 hours.

In yet another email, the acting head of unit of the ED, Katrina Romualdez writes that “there are only 11 confirmed discharges across the hospital today”, the situation has been “escalated” and “we are waiting to hear re hospital plan to unblock the ED”.

I have not seen it this bad before

In one response, SA Health chief executive Dr Chris McGowan acknowledges “the sustained hard work from everyone in your service to respond to the high demand currently being experienced”.

“I am aware that this has required extraordinary effort,” he says.

He says “collaboration across the system is needed” and explains he was advised the Northern Adelaide Local Health Service was “assisting to reduce the number of forensic outlier patients in CALHN”.

In her earlier inspection report from March 1, Mulholland writes there were 27 mental health patients waiting in the ED and eight patients who had been waiting more than two days.

At the time of her inspection, the longest wait had been 88 hours and doctors advised her “behaviour and self-harm is escalating”.

One doctors told her “I have not seen it this bad before”.

She said one cardiac patient had been in the ED for 34 hours.

“The doctors advised the floor was unsafe to work on for both patients and clinicians, creating immediate stress and anxiety,” she said.

Another doctor reported that the local health networks were “prohibited” in “assisting each other when a hospital is in difficulty” because of the way the LHNs were structured “and the KPIs allocated to each LHN to meet”.

Mulholland has sent copies of her reports to the Health Minister, Mental Health Commissioner, Health and Community Services Complaints Commissioner, the head of CALHN and the chief executive of SA Health.

In a statement, a spokesperson for SafeWork SA confirmed “we have received from SASMOA two entry permit holder reports relating to their entries made at the Royal Adelaide Hospital in March 2021”.

“Inspectors have been allocated to these matters and we are unable to provide further information,” the spokesperson said.

A spokesperson for SA Health said “as the regulatory body, it’s the role of SafeWork SA to determine if any workforce health and safety has been breached”.

“No such determination has been made in relation to the views expressed by SASMOA,” the spokesperson said.

InDaily has also contacted Health Minister Stephen Wade for comment.

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