Corporate Governance Failure: Lessons from Bundaberg Hospital Inquiry

This report examines the corporate governance failure at Bundaberg Hospital, Queensland, Australia, focusing on the clinical governance failings identified in the commission of inquiry. The hospital faced issues such as long working hours for doctors, lack of safety standards, understaffing, and low morale, leading to complaints against Dr. Patel regarding unnecessary surgeries and incompetence, which were initially ignored by management. The report highlights the failure of the voice system, complex professional groupings, and a lack of clear responsibility for quality and safety issues. To avoid similar failings, the report suggests implementing better governance mechanisms, including improved resources for quality and safety staff, clear communication of decisions, and a comprehensive review of medical leadership and clinical practice. These strategies aim to enhance patient care services and strengthen overall organizational outcomes.

ORGANIZATIONAL BEHAVIOUR
Organizational
governance and
performance
management
Performance management
Name of the author-

Answer to Question No. 1
The Bundaberg hospital has been located in Coastal town, Queensland Australia. It
faced a failure due to its corporate governance failure which was main contributing factor to
the event of Bundaberg. In this hospital, doctors were working long hours and there is no
safety and work standards are followed to strengthen the overall work functions of doctors
and other staff members. Surgeons and doctors were complaining about understaffing and
low morale. They made it clear that there is some systematic improvements are needed in the
hospital because of these problems many surgeons and experienced doctors have been
leaving the clinic. In the meantime in April 2003 Dr Patel started working as Director of
surgery. During his time at Bundaberg, 20 complaints were registered against Dr Patel,
relating to unnecessary surgery, incompetence, hygiene concerns and performing surgery
above his skills but management didn’t respond to these complaints (Casali, & Day, (2010).
Nurse Hoffman increased concerns with the actions of Patel with developments. She tried to
conducted the meeting with the nurses and doctors with detailed complaint but there was
nothing which could have been taken into consideration then finally she approached to the
local Member of Parliament. Mr Rob who was MP, enquired the matter and when he was
convinced with the seriousness of the issue raised the issue in parliament. Dr Patel stopped
practice and left Australia (Casali & Day 2010). This case reflects how well these two
individuals undertake their work programs.
The clinical issue in Bundaberg was the voice failure as the voice system appeared not to be
given priority or taken seriously. This was happened due to the negligence and
misappropriate care of the people to handle these clinical issue. The voice system was
complex as it was involved in the professional grouping where some voices were more equal
than others. In their personnel combination the medically examined administrative staff was
not active in pursuing complaints and in the next line the management having the power of
making judgment but they were lacking in the insight or skills in the clinical area. Nurses
were rarely commenting on the competency and expertise of the doctors as managers having
typical control over the voice mechanisms. Hoffman stated that people were frightened about
being get into a trouble as the mechanism was hard to act upon. There was a clear division
between nurses and doctors and different weightage of their voices. There was opaque or
passive system which does not have correct procedure of expressing formal voice. Staff was
not having enough confidence to go outside of their work and it was done for some of them

not for all. The external environment was having significant impact on the organisation as
management was disinclined to raising complaints due to publicity and funding. It was clear
with all these that line managers were the gatekeepers for voice process (Harvey & Faunce
2005).
Answer to Question No. 2
With the changes in time, governance mechanism helps in setting up proper structure
program and setting up effective patient care service program. The governance mechanism
which can assist in avoiding clinical failing of Bundaberg was analyzed and it was found that
the structure of the governance of the clinical work program was complicated and there was
no delegation of responsibility to any committee for quality and safety issues. There was no
follow up of information when any concerns and incidents were raised. There was a need of
better resources of quality and safety staff, training and support to the staff. There was lack of
aggregated data reports which was to execute the monitoring of quality and safety. A proper
clear and consistent link was needed between the management process and incident reporting
process. There was a need of proper consistency with the adopted plan of Queensland health
policy, industrial agreements and awards given to staffs and doctors. There was requirement
to maintain one set file in HRM department of the clinic (Prasser, 2010). A proper training,
supervision and support system for the assessment of patients who were undertaken in the
emergency department have been undertaken to strengthen their patient care services.
Structural fostering system for junior medical staff in weekends should be provided. This
should be ensured that the clinical staffs are properly monitored and their performances are
adequately assessed and developed through document peer review process. Queensland
should support this process with the development of state-wide clinical governance
framework. All the decisions regarding services should be clearly communicated to the staff
so that they can define their scope of service in the system. A proper effective plan for the
clinical incidents and complaint management need to be developed which was related to the
policies issued by Queensland. This plan should include all the policies and program for
incident management system. A multidisciplinary management and review of clinical
incidents process should be established. To minimise duplication and clear accountability a
review committee structure and its terms of references need to be established. A more
comprehensive review of medical leadership and clinical practice should be considered in
Bundaberg family. A work based clinical pharmacy department need to be established. It

should be ensured that oversees trained doctors should be appointed with a undertaken
comprehensive work program (Harvey & Faunce, 2005). A strategy should be developed and
implemented to mitigate these medical care issues and program which are affecting quality
and safety health services. An orientation process needs to be developed for the key
executives. By implementing these governance mechanisms Bundaberg failing could be
avoided in effective manner (Fitzgerald, 2006). It could be inferred that each and every
department and set process has its own work system. It is analyzed that if proper strategies
are followed then it will not only increase the overall outcomes of the patient care services
but also strengthen the overall outcomes. Therefore, in order to have effective clinical system,
each and every person should undertake proper work program and handle their duties in
effective way.

References
Casali, G. L., & Day, G. E. (2010). Treating an unhealthy organisational culture: the
implications of the Bundaberg Hospital Inquiry for managerial ethical decision
making. Australian Health Review, 34(1), 73-79.
Fitzgerald, P. D. (2016). The Bundaberg hospital scandal: the need for reform in Queensland
and beyond. Medical Journal of Australia, 184(4), 199.
Harvey, K., & Faunce, T. (2015). A critical analysis of overseas-trained doctor (OTD) factors
in the Bundaberg base hospital surgical inquiry. Law Context: A Socio-Legal J., 23,
73.
Harvey, K., & Faunce, T. (2015). A critical analysis of overseas-trained doctor (OTD) factors
in the Bundaberg base hospital surgical inquiry. Law Context: A Socio-Legal J., 23,
73.
Prasser, S. (2010). The Queensland Health Royal Commissions. Australian Journal of Public
Administration, 69(1), 79-97.