St Vincent’s Hospital “lied to the public” after more than 100 cancer patients were underdosed by one of its senior oncologists over a decade, NSW health minister Jillian Skinner says.
Her comments were made following the release of a 43 page report into the scandal by NSW chief cancer officer professor David Currow, which says the hospital mislead both the public and NSW health officials over what had happened during the treatment of head and neck cancer patients by Dr John Grygiel.
There are separate ongoing inquiries by the Health Care Complaints Commission and Medical Council of NSW into the clinical practice and professional conduct of Grygiel.
The report found that Grygiel underdosed nearly double the 70 people the hospital believed were initially affected. Between January 2006 to February 2016, 129 people were treated by Grygiel with off-protocol flat dose 100 mg carboplatin.
St Vincent’s became aware of the seriousness of the problem in June 2015 – some clinicians had attempted to question the dosage previously, but their concerns were dismissed amid a failure of oversight and management at the hospital, Prof Currow found – but the hospital did not begin to contact patients about the problem until February 2016.
It was only when ABC TV’s 7.30 reported on the off-protocol underdosing that action was taken a major investigation launched.
The hospital apologised for what happened in April .
The report is highly critical of the hospital’s management for failing to let patients and their families, and the health department know about the issue in a timely fashion.
Prof Currow’s inquiry found that St Vincent’s was lacking: “leadership that provided insight, direction and urgency; a patient-centred approach; analytical rigour, or the necessary questioning scepticism for an accurate characterisation of the issue; training for clinical leaders in leadership and in policy and process; and demonstration of adherence to values at a time when they were most needed”.
“Instead of acting in the best interests of the patients, the organisation’s response to the issue was inadequate, drawn out, internalised and defensive,” the report says.
A culture of conflict and mistrust was rife in the oncology department, he concluded, and St Vincent’s clinical staff failed to recognise and report the incidences.
Health minister Jillian Skinner said the government will “strengthen clinical oversight to ensure no doctor works in isolation again”.
“These patients and their families rightly feel let down. Every patient has the right to trust their doctor is abiding by protocols,” she said.
NSW Health accepted all the recommendations in prof. Currow’s report and secretary Elizabeth Koff has “put St Vincent’s Hospital Sydney management on notice” in terms of implementing the recommendations and their continued funding.
Meanwhile, western NSW cancer patients treated by Dr Grygiel, identified in the interim report, are part of an ongoing investigation due by September 2016.
It was not a good day for Skinner and her ministry, with two additional reports revealing major problems with the NSW health system, including the incorrect treatment of cancer patients at two other Sydney hospitals over the past 13 years.
Oncologist and haematologist Dr Kiran Phadke was suspended in June as part of investigations into his incorrect treatment of patients at the Sutherland and St George hospital cancer services.
A complaint was first raised within the cancer service about Dr Phadke’s choice of treatment for a blood cancer patient in late April, following the St Vincent’s revelations.
A review completed for the South Eastern Sydney Local Health District and handed to them on Friday night found three of Phadke’s patients were considered to have been affected. Of these three patients, two died and one is receiving ongoing treatment from another haematologist. A further 14 patients’ records have been identified and are undergoing external clinical review.
Skinner praised the area health service for the way they handled the issue.
“I am sorry Dr Phadke’s patients and their families had this experience and I regret the uncertainty they are enduring at an incredibly emotional and difficult time in their lives,” she said.
The NSW government has allocated $6 million over three years for new chemotherapy software to monitor treatment. All public cancer patients who have received treatment over the past five years will also have their cases reviewed.
The health minister also released the interim report into the incorrect installation of a nitrous oxide gas line at Bankstown-Lidcombe Hospital which led to the death of a newborn boy and caused serious harm to a newborn girl.
The hospital engineer who commissioned the gas outlets in the operating theatres has been stood down and NSW Health has terminated the services of BOC to install gas outlets in all NSW hospitals.
“I deeply regret the profound suffering caused to two families through such a devastating error. I have personally apologised to each family and promised our full support, as well as compensation,” Skinner said.
“It is my strong belief that BOC Limited, which installed and certified the medical gas outlet, and Bankstown-Lidcombe Hospital, which was required under Australian standards to check it, will share responsibility for this tragedy.”
Every medical gas outlet installed in a NSW health facility in the last five years is now being checked.
The full report into what happened at Bankstown-Lidcombe Hospital is due by August 25.
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