Analysis of BBH Health System Failure and Inquiry (NSG3EPN)

This report examines the health system failures at Bundaberg Base Hospital (BBH) in Queensland, Australia, focusing on the issues surrounding Dr. Jayant Patel and the subsequent inquiry. It analyzes the failures in clinical governance and quality and safety, highlighting the lack of internal oversight and risk management. The report discusses the role of the Morris and Davies Inquiries, exploring the impact of these failures on public trust and the professional consequences for those involved. It also explores the challenges related to overseas-trained doctors and workforce shortages, and the need for effective complaint management systems. The report provides recommendations for improving clinical governance, healthcare quality, and safety within the hospital, including the implementation of standardized Root Cause Analysis and the adoption of robust risk management strategies to prevent future health system failures. The analysis emphasizes the importance of external and internal quality control mechanisms and the need for effective responses to whistleblowing to ensure patient safety.

Examining a public inquiry
into a health system failure
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Table of Contents
Introduction......................................................................................................................................2
Clinical Governance........................................................................................................................2
Quality and Safety...........................................................................................................................3
References........................................................................................................................................6

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Introduction
The fundamental purpose of the paper is to explore prominent inquiry into health system failures
that may undermine public trust in the health system and can be highly visible to the community.
The professional and potential personal impact creates an impact on those engaged in inquiry.
The professional and personal impact may be justifiable if there possess some positive change
within the system that manages the negative impact. The paper will examine the health system
failures that occurred in Bundaberg Base Hospital (BBH) by addressing two modules those are
clinical governance and quality and safety in the Australian context. It will analyze the role of
inquiries into health system failures and strategies that may help in preventing such failures.
Based on the case study, the paper will explore the issues related to Dr Patel at BBH in
Queensland. It will provide by providing recommendation for improving clinical governance
along with healthcare quality and safety in the hospital.
Clinical Governance
Clinical governance is determined to be a framework that helps health services to safeguard
standardized care and improve the quality of services by generating an environment that
flourishes excellence in clinical care. In the developed countries like Australia, most of the health
care organizations possess an array of clinical governance systems like clinical privileging,
credentialing, morbidity and mortality review, clinical audit and incident analysis and reporting.
Based on Dr Patel case in Bundaberg Base Hospital (BBH), it was analyzed that none of the
numerous incidents of poor clinical outcomes and negotiated patient care was investigated by the
internal clinical governance systems of the hospital (Thiele, 2019). On April 2005, under the
guidance of Commissioner Anthony Morris QC, the Bundaberg Hospital Commission of inquiry
was launched. The Interim Report of Morris Inquiry called Dr Patel to be charged for
manslaughter, murder, negligence, fraud and false representation. The inquiry was closed on
September 2005 after inquiry evidence for fifty days in Queensland Supreme Court. The Morris
Inquiry was not allowed to last longer as the court believed that the evidence stained through
unfairness that cannot be detangled from the entire proof. Whereas, as per the final report of
Davies Inquiry, it is declared that Dr Patel was charged with several offences as per the
Queensland Criminal Code. As per Foster's Review, the clinical governance system of the

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hospital failed to manage the clinical risks that influenced system failure. In other words, the
hospital setting did not seem focused on the area of risk management that led to poor clinical
outcomes (McGoldrick, Ulahannan & Krebs, 2016). At BBH the failure of external and internal
quality assurance devices along with risk management resulted into a inquiring of whether the
Australian healthcare system faces difficulty in carrying out basic management, reporting and
monitoring of medical errors. Thus, Australian clinical a governance system needs to determine
specific regulatory issues related to overseas trained doctors (OTDs) that include a minimum
level of competence, potential institutional, legal liability and assessment and monitoring.
On the other hand, it is acknowledged that workforce issue results in poor clinical governance
that influenced hospital public inquiry. It is seen that feminization of the medical workforce,
which means that female medical professionals work for fewer hours as compared to male
coworkers due to their child-rearing role. These factors lead to a lack of medical professionals.
However, retaining of OTDs in remote and rural areas becomes complex (Nowotny, Loh, Lorenz
& Wallace, 2019). Another critical situation is increasing international competition to appoint
health professionals. The position statement of OTD must emphasize Australian international
responsibility to make sure that it explores Australian-trained doctors to have sufficient and
appropriate medical workforce to satisfy the health needs of the population in the future.
However, to mitigate the issue of poor clinical governance and shortage of workforce, the
Australian medical services have implemented orientation programs that include the role of
junior doctors, culture shock sessions, health and workplace skills and communication. The
program enables the OTDs to enter into public hospital system that leads to the functional,
confident and integrated workforce.
Quality and Safety
To prevent the health system failure, BBH must have used risk management strategy like
monitoring and responding to complaints. The hospital must have planned to implement an
effective complaint and clinical incident management that is sustainable with Queensland Health
Policy. This must involve the adaption of the complaints management information system by
considering designated patient safety and customer liaison officers to support the district.
Moreover, it is significant for the hospital to make sure that the documents raising concerns or
complaints are signed and dated by the staff members who monitor the concern or complaint.

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The staff members within the hospital must be provided with comprehensive support and
training in managing clinical complaints and monitoring the processes at Bundaberg Health
Service District (Wilkinson, Townsend, Graham & Muurlink, 2015). This must involve
standardized Root Cause Analysis (RCA) method. The implementation of complaint
management systems is determined to be the quality control measures that would have prevented
the hospital from facing such health system failure. Utilizing and monitoring the information
received from the customers helps in enhancing organizational performance. It is seen that
improvement in service helps the organizations in handling complaints at the individual level and
analysis and collation of aggregated complaint data. BBH must follow the following complaints
management performance standards:
 Implementing local processes to enhance best practices in handling customer complaint
 Staff and customer rights need to be supported all over the process
 Actively promote and encourage customer feedback
 Integration of compliant information into the activities of organizational improvement
The adoption of this particular risk management strategy might have played a significant role in
changing the outcome in the inquiry. The strategy possesses the capability to prevent system
failure and enhance the flow of information when concerns or incidents were raised along with
ongoing evaluation and feedback to staff members. This would have provided the hospital with
appropriate resources related to quality and safety to help the staff members to monitor quality
and safety. The strategy might have also helped in establishing a consistent and clear link with
the process of complaint management. The strategy is capable of helping BBH in avoiding the
negative inquiry outcomes and served positive outcomes (Young, Hulcombe, Hurwood &
Nancarrow, 2015). An efficient implementation of this strategy must create a positive impact on
the use of traditional assurance mechanisms by Dr Patel that helps in recognizing frequent and
incompetence adverse clinical inquiry outcomes. It would have helped the hospital setting to
improve external quality control mechanisms that help in identifying the health system failure in
fully-accredited facilities. Moreover, the external quality control mechanisms like hospital
accreditation procedures and the Australian Incident Monitoring System (AIMS) would have
effectively exposed the events at the hospital (Murray, Sundin & Cope, 2018). With the help of
this strategy, the hospital might have responded positively to whistleblowing by the nurse

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regarding the poor surgical performance of Dr Patel. As a result, this must-have helped the
hospital, along with Dr Patel to fulfil the expected level of safety and quality.

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References
McGoldrick, C., Ulahannan, T., & Krebs, K. L. (2016). Review of antibiotic use in respiratory
disorders at a regional hospital in Queensland. Collegian, 23(4), 391-395.
Murray, M., Sundin, D., & Cope, V. (2018). New graduate registered nurses’ knowledge of
patient safety and practice: A literature review. Journal of clinical nursing, 27(1-2), 31-
47.
Nowotny, B. M., Loh, E., Lorenz, K., & Wallace, E. M. (2019). Sharing the pain: lessons from
missed opportunities for healthcare improvement from patient complaints and litigation
in the Australian health system. Australian Health Review, 43(4), 382-391.
Thiele, D. (2019). Retrieved 26 August 2019, from
http://www.qphci.qld.gov.au/final_report/Chapter-03.pdf
Wilkinson, A., Townsend, K., Graham, T., & Muurlink, O. (2015). Fatal consequences: an
analysis of the failed employee voice system at the B undaberg Hospital. Asia Pacific
Journal of Human Resources, 53(3), 265-280.
Young, G., Hulcombe, J., Hurwood, A., & Nancarrow, S. (2015). The Queensland Health
Ministerial Taskforce on health practitioners’ expanded scope of practice: consultation
findings. Australian Health Review, 39(3), 249-254.