Public Inquiry into Health System Failure

Running head: PUBLIC INQUIRY INTO HEALTH SYSTEM FAILURE
PUBLIC INQUIRY INTO HEALTH SYSTEM FAILURE
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1PUBLIC INQUIRY INTO HEALTH SYSTEM FAILURE
Introduction
The following paper will demonstrate the key inadequacies in terms of healthcare quality
during the inquiry of the failure to deliver optimum patient and healthcare services by the
healthcare organization at Bundaberg Hospital, Queensland. The two modules which will be
examined here with regards to this case is ‘Quality and Safety’ and ‘Organizational Culture’.
Module 1: Quality and Safety
One of the key areas which could have contributed to an escalation of the high risk
incidences and hindrances to patient safety in the Bundaberg Hospital is the lack of adherence to
standards of quality and safety within the organization. There was clearly a lack of
implementation of strategies pertaining to quality and safety, mainly: accreditation and
benchmarking and monitoring, responding to complaints and reporting and acting upon near
misses and incidents
A quality and safety strategy of prompt reporting and acting upon occurrence of adverse
incidents or misses involves the organizational management and healthcare professionals to
promptly work towards mitigation of any situation which may be potentially life threatening for
the patient (Lee, 2017). In case of the Bundaberg Hospital, it can be observed that despite the
staff being well aware that Dr. Patel was engaging in gross medical negligence, surgical errors
and manslaughter, there was absolutely no attempt by the organization to prompt resolve these
high risk, adverse consequences, leave alone terminating the Patel. To combat such
discrepancies, the hospital could have adhered to the National Safety and Quality Health Service
Standards (NSQHS) postulated by the Australian Commission on Safety and Quality in

2PUBLIC INQUIRY INTO HEALTH SYSTEM FAILURE
Healthcare (ACSQHC, 2017). This will involve adhering to Standard 1.11 where the Bundaberg
Hospital could have engaged in a risk management strategy of incident management,
investigation and open disclosure (ACSQHC, 2017). Such strategies could have prevented the
escalation of misconduct implemented by Dr. Patel as per these standards, staff would have
promptly recorded and reported associated incidents to higher authority for investigation as well
as take insights from these incidents to improve the safety and quality of patients opting for
surgery (Sujan, 2015). The Bundaberg Hospital could have adhered to the NSQHS quality and
risk management standard of 1.10 (ACSQHC, 2017). This would have involved staff of the
Bundaberg hospital to closely look into the risk posed by surgery for a patient with the help of a
risk assessment framework which could have promptly exposed the inadequacies reverted to by
Dr. Patel (World Health Organization, 2017).
One of the next strategy which could have been adhered to by the Bundaberg Hospital is
the process of monitoring and responding to complaints raised by staff and patients alike. It can
be observed that despite numerous cases of manslaughter, patient death and injury, there was no
mention of considering possible complaints raised by staff or families of the concerned patients
regarding the malpractices conducted by Dr. Patel. To prevent the same, the Bundaberg Hospital
could have adhered to NSQHS Standard of 1.14 of Feedback and Complaints Management
(ACSQHC, 2017). Such a quality and safety risk management strategy could have helped the
management of the Bundaberg Hospital since it would have prompted staff to immediately
scrutinized complaints against Dr. Patel and act against the same to prevent adverse health
consequences in patients (Nowotny, Loh, Lorenz & Wallace, 2019).
Lastly, a key quality and safety strategy which could have benefited the Bundaberg
Hospital is the compulsory implementation of accreditation and benchmarking standards.