Three Hospitals in the Pilbarra have sounded a belated alarm to all consumers of Hospitals Services in regional Western Australia. The WA Country Health Service (WACHS) today admitted that a doctor had consistently breached infection control protocols between July 7 2008 and April 1 of this year.
During an interview with the ABC, Executive Director of the Clinical and Workforce Reform at WACHS Felicity Jeffries was at pains to reassure the public that the risk of infection from blood born viruses arising from the breach was low, and that patient safety at all three hospitals was “of the highest standard.” In the circumstances, both these assessments are questionable.
A valid risk assessment would take into account not only the probability of infection arising, but also the degree of harm which might arise. It is common knowledge that infection with blood born viruses can have catastrophic consequences involving chronic illness, liver cancer and premature death. Therefore, regardless of Ms Jeffries view of the risk, the real risk to the patients affected must be assessed as high, by any reasonable standard.
When reporters during an interview asked Ms Jeffries to explain the nature of the breach, and whether for example it involved the re-use of syringes, she dodged the question by saying that it was a procedure involving the delivery of short term anaesthetics, and it was “quite complicated to explain.”
But infection control procedures are routine and very clear, and they apply to all staff having contact with patients, and particularly those involved in procedures such as the delivery of intravenous drugs, as in the case of anaesthetics. While the pharmacology of the anaesthetic might be complicated, the protocols involved in delivering it are spelt out in simple terms on behalf of all staff involved.
Ms Jeffries said that the breaches involved only one doctor, and they had been suspended from duty and reported to the Medical Board. But this would only be true if the doctor had been working in a vacuum. Instead, he was a member of a medical team, and the rest of that medical team are still on duty, and under the same “highest standard” supervision.
How can a doctor work at three hospitals over a period of six hundred and thirty-nine days and not have any of their colleagues or supervisors notice that the procedure they are using to deliver drugs is twenty years out of date?
Clearly the failure went beyond the individual doctor, and beyond an individual hospital. It is for this reason that the warning sounded in the Pilbara should be heard by all regional health services and their clients, because they are all subject to the same supervision of WACHS.
While it might be a consolation to the patients affected that the Health Department is offering “someone to talk to” if they have concerns, of more importance is that the failure of any doctor to adhere to the protocols associated with any treatment effectively nullifies any consent which they might have obtained from the patient. This is a key issue, given that consent is required for the delivery of anaesthetics, as laid down by the WA Health Departments own Consent Standards.
It is implicit in any medical consent in a Hospital setting that the procedure will be performed in accordance with the safety protocols currently in place. It can therefore be argued that in each case where the infection protocols were not followed, there was a failure of consent, giving rise to serious potential for criminal and civil claims of assault.
Ms Jeffries needs to explain how for more than six hundred days no one noticed that the infection control protocols were being breached in at least these three hospitals, and by at least one doctor. The number of staff who would have passively witnessed those breaches and failed to act must number hundreds, all of whom have so far escaped scrutiny for their complicity in the failure.
No breach of protocol can continue over such a length of time without a complete failure of the checks and balances that are fundamental to even an average standard patient safety system. It is reasonable to conclude on the evidence that patient safety in the Pilbara is currently non-existent, and the breach identified is but the tip of an iceburg.
Ms Jeffries should come clean.