HM Jillian Skinner faces trifecta of serious hospital errors

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NSW health minister Jillian Skinner has copped a fierce barrage of criticism as a cluster of major hospital scandals were laid bare in a single day. On Tuesday, Ms Skinner faced renewed calls to resign and damaging questions over critical errors under her watch, after she delivered the findings of separate investigations into the St Vincent’s chemotherapy dosing scandal, and the fatal neonatal gassing error at a Sydney hospital

A hospital engineer has been stood down and BOC Ltd has had its hospital contracts suspended after nitrous oxide was incorrectly delivered to two newborn babies at Bankstown-Lidcombe Hospital, leading to the death of a baby boy and the permanent brain damage of a baby girl.

A total of 36 babies were born in the operating theatre with affected gas outlets, a report by the Chief Health Officer found. Only two babies were treated in the resuscitation unit where the gas was delivered.

“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,” Ms Skinner said as she fronted the media.

She said BOC was responsible for the commissioning and installation of the gas line and “will share responsibility for this tragedy”.

But a spokeswoman for the medical supply company has fired back, raising questions about the extent of its culpability.

“[The] medical oxygen and medical nitrous oxide pipelines were incorrectly labelled prior to BOC’s work being undertaken at the hospital in July 2015,” a spokesperson for the company said.

Documents showed that both a hospital representative and a BOC contractor were involved in the commissioning of the single oxygen outlet where the fault was found, she said.

Compounding a horror day for the ministry, Ms Skinner released a separate scathing report  that found St Vincent’s hospital had misled the public and the government over oncologist Dr John Grygiel’s incorrect dosing of more than 100 head and neck cancer patients.

A senior staff member has lost their job over the fiasco.

The final report lambasted the hospital’s senior management for failing to alert patients, their families, and the health ministry to the systemic dosing errors after they first became aware of the problem in June 2015.

“The hospital lied to the public, there’s no question about that,” said Ms Skinner on Tuesday.

“It’s a very critical of the practices at St Vincent’s hospital,” she said.

NSW Chief Cancer Officer Professor David Currow, who led the inquiry, said “misleading” statements to the public “had executive sign-off at several levels”.

Dr Grygiel gave 103 patients – at least 30 more than first reported – off-protocol doses of the chemotherapy drug carboplatin at the inner-Sydney hospital between 2006 and June 2015, the inquiry found.

The inquiry found no compelling reason to explain why Dr Grygiel chose to administer flat doses of the chemotherapy drug, which dipped between half and one-third of the recommended levels and was not supported by clinical evidence.

NSW Health launched the inquiry in February after the hospital was forced to admit the dosing errors following media exposure.

St Vincent’s chief executive Toby Hall Hall apologised “deeply and unreservedly” to the patients and families affected and acknowledged the original statements publicly released by the hospital were inaccurate.

“But at no stage did the hospital set out to deceive,” he said.

“I personally raised this matter with the head of the inquiry and asked if he had any evidence to suggest that hospital staff had intentionally mislead the public. And he responded that he had no such evidence,” Mr Hall said.

Mr Hall said a chief medical officer chose to resign or their own volition, and declined to comment further.

“At the heart of this situation is a doctor who incorrectly treated patients,” he said.

The number of affected patients is expected to rise as the inquiry continues to investigate a large number of cancer sufferers treated by Dr Grygiel at outreach clinics in Bathurst and Orange. Professor Currow said he would release findings concerning the clinics on September 16.

In a statement via his lawyer, Dr Grygiel said “the report contains no evidence that a higher dose would have been more effective or that my treatment has caused harm to any patient”.

On Tuesday the health minister also chose to reveal another doctor had been incorrectly under-treating cancer patients for more than a decade.

Dr Kiran Phadke, an oncologist and haematologist at Sutherland and St George hospitals, was suspended in June.

A review found three of his patients had been affected by his choice of treatment, including fears of incorrect dosage. Two have since died and the records of another 14 patients are being reviewed.

Ms Skinner defended the timing of her public disclosure, saying “I will never reveal anything to the media until I feel confident that there’s been proper professional analysis”.

She dismissed the suggestion that she had lost control of the Health Department in light of the three emerging scandals.

Under coordinated attack from Labor, Ms Skinner refused to rule out that more patients and hospitals might be drawn into the under-dosing affair.

Opposition Leader Luke Foley repeated calls for Ms Skinner to resign, accusing her of being an  “apologist for hospital administrators”.

“Mrs Skinner finds it nigh on impossible to take responsibility for what has happened on her watch,” he said. “Information is selectively released; it’s delayed”.

The government has allocated $6 million over three years for new electronic prescribing software to track chemotherapy prescribing.

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