UNEXPECTED DEATHS IN NQ HOSPITALS: CRITICAL ANALYSIS

PATIENTS dying as a result of falls and one who died after not receiving adequate post- operative care are among 13 “unexpected” deaths at North Queensland hospitals within a 2 ½ - year period.

The serious clinical incidents between January 1, 2014, and July 31, 2016, have been revealed through a heavily censored Right to Infor- mation report obtained by the Bulletin. These cases are known as a Severity Assessment Code ( SAC) 1 clinical incidents – defined as “death or likely permanent harm which is not reasonably expected as an outcome of healthcare”.

A total of 288 incidents were identified across the state with the Townsville Hospital and Health Service recording five of those in 2014, four in 2015 and three in the first seven months of 2016.

By comparison the Cairns and Hinterland district recorded 13 cases and Mackay district registered 27.

The location of 44 incidents, including multiple patient suicides and one where a baby whose heart rate was “flat” after birth was then dropped by a staff member and subsequently died, have been redacted.

The names, ages and genders of all patients and staff involved have also been withheld.

Townsville Health and Hospital Service ( THHS) chief operating officer Kieran Keyes said in the time covered by this RTI request, the hospitals in the Townsville district had more than 230,000 emergency department presentations, admitted more than 150,000 people to hospital and performed more than 30,000 surgical procedures. He acknowledged that when things did go wrong, it was “incredibly distressing for patients, their families and our staff”.

“The overwhelming majority of this care is provided safely by our professional, world- class staff and results in excellent outcomes for our patients,” he said.

“However, sometimes care does not go as expected and in some cases adverse health outcomes occur.

“The Townsville HHS has a culture of patient safety that encourages staff to report clinical incidents and when an incident occurs we review it to provide ways to prevent it from happening again.”

Queensland Health said while the HHS boards had a responsibility to monitor the safety and quality of their service, the department likewise had a similar responsibility in setting standards and monitoring these.

Under the Queensland Health Patient Safety Health Service Directive, Hospital and Health Services ( HHS) are required to conduct a review of the SAC 1 incident and submit an incident analysis report. This