NSG3EPN: Analysis of Bundaberg Hospital Inquiry into Health Failure

This case study examines the 2005 Bundaberg Hospital incident in Queensland, Australia, highlighting failures in the healthcare system related to clinical governance, quality, and safety. The inquiry revealed negligence by hospital administration and questionable clinical practices by Dr. Jayant Patel, leading to surgical errors and patient deaths. Failures included inadequate credential checks during Dr. Patel's recruitment, lack of leadership, and a defensive organizational culture that suppressed concerns raised by staff. The complex structure of the clinical governance committee, coupled with poor incident reporting and feedback mechanisms, hindered effective monitoring of quality and safety issues. Recommendations include promoting professional training, improving credential verification processes, and fostering open communication channels to prevent similar incidents in the future. The case underscores the importance of addressing medical racism and reinforcing quality and safety policies within the Australian healthcare system; find similar resources and solved assignments on Desklib.

Case Study of Bundaberg Hospital

Introduction
The article focuses on aspects related to quality of health care system and safety
related investigations in Australia. One of the incidents that occurred in 2005 at
Bundaberg hospital in Queensland, Australia is exploited and highlight the reasons
for failure of Australian health care system. Clinical governance and quality and
safety issues were discussed with regard to failure of health system that lead to
numerous surgical errors and patient deaths.
Clinical Governance
One of the reasons for failure of health care system in Bundaberg hospital is clinical
governance. The reasons for failure of clinical governance was inquired and
investigated and reasons were due to irresponsibility and negligence of the hospital
administration and also decisions and clinical practices conducted by Dr.Jayant
Patel.
The members of Bundaberg hospital administration and medical board of
Queensland lacked responsibility and showed negligence while recruiting Dr. Jayant
Patel as Senior medical officer in surgery in the year 2003.The department of
administration failed to check the credentials related to Dr. Patel. In addition to this,
administration failed to assess the criteria of selection for the post and were unable
to perform proper assessment before allocating the post to Dr.Patel. This clearly
indicates there is a lack of leadership qualities and cultural differences with regard to
decisions made by Dr.Jayant Patel.
Dr.Patel was associated with several clinical related failures including death of
patients and this is mainly due to negligence and poor clinical practice. Previously in
1984 Dr.Patel was cited for not examining the condition of patient properly before
doing surgery and for this reason surgical related practices were restricted. Dr.Patel
was accused due to manipulating reports relevant to operation theatre and also
neglected, harassed and abused patients (Austin et.al,2015). Due to lack of
standard clinical practices it is not easy to get a post like Head of specific department
but Dr.Patel with all failures still got appointed as Head of surgery at Bundaberg.
This clearly shows decisions took by management lack leadership qualities and
shows negligence. Toni Hoffman, nurse at Bundaberg hospital highlighted the failure

of management of Dr.Patel’s clinical practices. Hoffman initially filed all the failures
and submitted to officials a report which never got any prompt reply. However she
gathered all the data related to operating procedures carried out by Dr.Patel and also
reasons for death of patients and submitted to Parliament member in the state. This
led to inquiry and found that the culture in the organization is defensive and hiding
the failures committed by Dr.Patel. Both leadership and culture values in the
organization are lacking and mishandled the entire situation by the administration
(Bismark & Studdert, 2013).
Leadership qualities were failed especially in making decisions at crucial juncture
and misused power by not reacting to the circumstances and covered up the issues
by maintaining silence. The hospital at culture lacks team work, coordination and
behaviour all these factors exploited during inquiry at Bundaberg hospital. Because
of lack of leadership qualities and constant bullying it resulted in resignations of
many employees specifically the staff associated with medical operating procedures.
In Bundaberg hospital inquiry it shows both transparent and open leadership
qualities were lacked by Dr.Patel and also hospital management. Because of
cultural differences it requires proper training about the medical procedures and
attaining leadership qualities. However Dr.Patel was not trained or made aware of
rules and regulations that are followed by Australian health care system. Dr.Patel
was not prompt in his duties and lacked required experience with medical
procedures. The safety of patients and delivery of prompt care were some of the
issues due to unprofessional behaviour of Dr.Patel.
Quality and Safety
The structure of clinical governance committee is found to be very complex and not a
single member in the committee took responsibility regarding quality and safety
issues. The information regarding incidents are not backed up and also not provided
with proper feedback from the concerned staff. There is need for improvement in
evaluation procedures. Systems were placed that provide information regarding
incidents but however there are issues with the procedures and many concerns were
related to quality and safety. Data reports were not available and also there is a gap
between management and incident reporting unit which made difficult for executive

to monitor the quality and safety issues. There was very small evidence that mortality
and clinical audits were found to be variable specifically in general surgery ward.
There is necessary for improvement in quality and safety levels and it is achieved by
professionalism and proper management. Misused terms and conditions about
clinical norms brought about whistleblowing in Bundaberg hospital and official
request pursued with proposals to improve understanding security.
In the consequence of the request, basic thought included loss of trust in the board
and among clinical associates, and loss of trust from patients and the network.
Without first revamping trust, staff won't report mix-ups or different worries about
wellbeing. Effective execution of patient wellbeing methodology expects approaches
to pressure the expert obligation of staff to report worries about partners when they
accept there is a hazard to patients (Braithwaite et.al,2010).
Some of the strategies which could have changed the inquiry outcome include-
Promotion of professional training at work place and successful practicing will enable
all doctors, health care professionals to consider tasks appropriately and also able to
advice for assistants.
It is necessary to introduce professionalism while giving credentials and relevant
data should be cross checked and should be monitored and should participate in
programme that maintains standards of professionalism.
The administration should respond to the staff members regarding any queries or
conflicts that arise within the hospital. In Bundaberg case inquiry even after several
attempts made by nurse Toni Hoffman to disclose the information regarding
unacceptable activities by Dr.Patel to the management but due to unprofessionalism,
negligence at work place didn’t respond to the query or issue.
The possible recommendations related to Bundaberg hospital incident that could
have avoided include
Proper procedure should be applied to check and verify all the documentation and
experience before admitting Dr.Patel to the concerned post. Previous work history or

feedback from employees were not taken into consideration and also he lacks proper
specialization that requires to become a surgeon. But due to negligence the
administration didn’t consider all these facts and offered him a Job. This could have
been avoided by constructive professionalism at all stages of recruiting the person
for a concerned job. After going through the entire case it shows still medical racism
still exists and it should be avoided. The policies related with health care and
regulators should be made aware of quality and safety issues. All these issues that
happened in Bundaberg hospital should serve as catalyst in future for Australian
healthcare system.
References:
Austin, J. M., Jha, A. K., Romano, P. S., Singer, S. J., Vogus, T. J., Wachter, R.
M. and Pronovost, P. J. (2015).National hospital ratings systems share few
common scores and may generate confusion instead of clarity’, Health
Affairs, 34(3), p 423-430.
Bismark, M. M. and Studdert, D. M. (2013) .Governance of quality of care: a
qualitative study of health service boards in Victoria, Australia’, BMJ quality
& safety, 23, p 474-482.
Braithwaite, J., Westbrook, M. T., Travaglia, J. F. and Hughes, C. (2010). Cultural
and associated enablers of, and barriers to, adverse incident reporting’,
Quality and Safety in Health Care, 19(3), p 229-233.