Health system failures

Bundaberg Hospital, Queensland, Australia

• Queensland Public Hospitals Commission of Inquiry Report 2005
• “Inquiry into complaints made about a surgeon and the failure …..to address complaints and concerns”
  • 48 serious incidents (adverse events), resulting in 13 deaths
  • The background of the surgeon involved was not checked
    • “discreditable past would have been revealed”
      • previous disciplinary action against him
      • had been stopped from carrying out certain operations elsewhere
  • Other hospitals were reviewed as part of the inquiry
    • “Common problems resulting in inadequate, even unsafe health care, in some cases with disastrous results”

Safety and quality issues included

• lack of credentialing and privileging processes
• no review of performance
  • surgical audit ceased
  • lack of supervision
• complaints not investigated
• complaints not recorded

Further information:

Queensland Public Hospitals Commission of Inquiry

Another example :

Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 -1995

The Shipman Inquiry