Victoria’s health department is not giving quality and safety in healthcare the attention it needs to protect patients from harm, a hard-hitting review of hospital safety, published on Friday, has said.
The findings have prompted Victoria’s health minister, Jill Hennessy, to announce an overhaul of the state’s health system.
The review was led by the health program director at the Grattan Institute, Stephen Duckett, and was ordered after 11 newborn and stillborn deaths at Bacchus Marsh hospital were found to have been potentially avoidable.
The hospital’s maternity ward had a higher than average perinatal mortality rate despite catering for low-risk births, a previous review of the deaths and Djerriwarrh health services, which managed the hospital, found.
“Basically, we need a change in the culture and approach to monitoring safety and quality in Victoria,” Duckett told Guardian Australia.
“The health department in the past has left the safety and quality issue primarily to individual hospitals, and this meant many hospitals were left reinventing the wheel when it came to issues, and there was also a lack of support to those hospitals from the department.”
Duckett’s review found that many safety and quality issues identified across the state were due to cumulative budget cuts over time that had “gutted many departmental functions”.
“While the cuts were portrayed as improving government efficiency, the decline in the department’s ability to perform its core functions was lost to public view,” the report found.
Duckett said the cluster of baby deaths that prompted the review were harrowing and that his team’s recommendations, some of which have already been implemented, would help the department’s goal of eliminating avoidable harm to patients.
“When my daughter was born I cried for joy,” he said. “I can’t imagine what it must be like to lose a baby and then be told that death was potentially avoidable. The premise of this review was really to make sure we learn as much from those deaths as possible.”
Hennessy said on Friday the government accepted all recommendations made by the review. She announced a series of reforms, among them a new health information agency to overhaul the way data and information is shared across the health system; the creation of a Victorian Clinical Council to provide clinical expertise to government and health services; and that consultation would begin on a “duty of candour” law which would see health services made to apologise to any person harmed while receiving care and to explain what went wrong and what action would be taken.
Many of the reforms will be implemented within 12 months.
“We want to do everything we can to reduce avoidable harm in our hospitals, and make them as safe as they can possibly be,” Hennessy said.
“A goal of zero avoidable harm is an ambitious target, but one we have an obligation to do everything we can to achieve.”
She announced an additional $13m to fund the reforms, and the formation of a new agency, Safer Care Victoria, tasked with monitoring and improving quality and safety in the health system. The agency will be headed by world-leading clinician and researcher Prof Euan Wallace.