Public Inquiry Report: The Bundaberg Hospital Case Study Analysis

This report provides a detailed analysis of the public inquiry into the Bundaberg Base Hospital, focusing on the failures in clinical governance, patient safety, and quality assurance. The report examines the complex organizational structure, including the lack of effective incident reporting systems and the shortcomings in the regulation of overseas-trained doctors. It highlights the lack of monitoring and review of medical practices, particularly concerning Dr. Patel's performance, and the consequences of neglecting complaints about his competence. The analysis discusses the absence of a single committee to address safety and quality issues, the lack of feedback mechanisms, and the absence of aggregated data reports. The report also explores the importance of an effective risk management strategy, including monitoring, verification of qualifications, and continuous outcome monitoring, to prevent future incidents. The inquiry reveals how the failure of internal and external quality assurance mechanisms led to disastrous consequences, emphasizing the need for proactive measures in healthcare settings. This document is contributed by a student to be published on the website Desklib, a platform which provides all the necessary AI based study tools for students.

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Public inquiry
Name of the Student
Name of the University
Author Note

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Introduction
There have been public health inquiries both nationally and internationally into the failure
of the health system. It ensures delivery of safe and evidence based care. The paper deals with
the investigation into the Bundaberg Base Hospital/Queensland Health. In response to the
investigation, the paper discusses about clinical governance, safety, and quality.
Clinical Governance
The term clinical governance by the “Australian Council on Healthcare Standards” is
defined as the health system where responsibility and accountability is shared among the
governing body, clinicians, staff and mangers to minimize the risk and ensure patient safety
(Jones & Killion, 2017). The components of the clinical governance framework as per the
Victorian Clinical Governance Policy framework are identified and two of them are discussed in
this section
In the Bundaberg Base Hospital, the clinical governance structure was very complex. The
paper specifically discusses how the following components led to system failure.
Organisation & committee structure, systems and processes- there was a fault in the
internal clinical governance system. There was no incidence of poor clinical outcomes detected
in the organization or any incidence of compromised patient care. It was the most perturbing
aspect of the Dr Patel’s case. There was no consistent link found between incident reporting and
the process of compliant management (Terry & Lê, 2015). There was poor management of range
of clinical risks. The external quality control team (Australian Incident Monitoring System) did
not expose the hospital to the events. The incidents were also not exposed by the hospital

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accreditation processes. Due to the faulty structure and process of the Australian medical system,
the Bundaberg Base organisation was not competent even to carry out the basic monitoring,
reporting and management of medical errors (www.phcris.org.au, 2017).
Another faulty aspect of the organisation’s structure and processes was lenient OTD
(overseas-trained doctors) regulatory factors. Dr Patel joined Bundaberg Base as it was located
in an AON. The same was defined under Medical Practitioners Registration Act 2001. The AON
classification process was full of shortcoming (Beaupert et al., 2014). The blind acceptance of
the applications by Queensland Health for AON positions from public hospitals was a big
blunder. Further, there was lack of assessment of the registrants like Dr. Patel. The clinical
competence of such doctors was not scrutinised. As a visiting officer, the ability to provide the
surgical services at Bundaberg Base was not established. There was no rationale for promoting
Dr Patel’s from Staff Medical Officer to the position of Director of Surgery. He did not even
apply for this position (Edwards et al., 2016).
Reports review and performance - Dr. Patel’s was trained in US. His practice
disadvantage came from his training and education that took place in different setting. He has
practiced in cultural setting that was different in level of technology, disease patterns, form of
heath care delivery and treatment options, workplace hierarchies and etiquette differ markedly
from those in Australia. Based on initial medical qualification of Dr. Patel in India, he was
appointed as OTD in Australia. There was no additional training given for performance
improvement or reviewed his activities (Terry & Lê, 2015). Although Ms Hoffman raised
concerns about his practice and competence with management, staff and administration, the
coroner and police but in vain. There was no further review on these complaints on his
performance. Therefore, the health system failure in the Bundaberg Base Hospital is due to

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failure of quality assurance mechanism both at internal and external level. However, when the
allegations against the doctor become public, the inquiry was lunched.
Safety and Quality
In the Bundaberg Base Hospital, the clinical governance structure was very complex.
There was no delegation of single committee to tackle the safety and quality issues. There was
lack of follow up on events been occurring. In case any concerns, events, or incidents were
raised there was no flow of information. The staff provided no feedback and there was no
ongoing evaluation for improvement. The incident reporting system was in place but in vain.
There were number of concerns raised in response to the resources available in safety and the
quality unit. There was also frequent incidents where the staff complained about lack of training
facilities and support followed the inquiry of Dr. Patel’s case (Chandler, 2017). Further, there
was lack of aggregated data report on surveillance that will help the executive to monitor the
safety and quality. There was little evidence found in regards to the departmental clinical audits,
and mortality audits. The clinical audits in the general surgery were variable. However, by
Monitoring and responding to complaints, this issue would have been resolved.
Monitoring and responding to complaints
If the above-mentioned risk management strategy had been in place, an immediate action
would have been taken against Dr Patel. Initially MS Hoffmen, blew the whistle regarding this
doctor. The complaints regarding the incompetence and practice of Dr. Patel were neglected.
She even highlighted that together with staff she hid patients from Dr. Patel (Watson, 2016). The
administration was however, inactive and apparently unwilling to investigate the issue. If it was
earlier monitored that a number of patients suffered serious complications after being treated by

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Dr. Patel, he death cases would have been prevented. Responding to this whistles early would
have led to early detection of Dr. Patel’s past black records. In addition, an investigation should
have been started before the public disquiet about the quality and safety of Queensland public
hospital services (Wilkinson et al., 2015).
The risk management strategy could have prevented such disastrous consequences if
following actions was taken after complaints against Dr. Patel-
 If there was monitoring to identify if Director of Surgery position was an AON
position. Verifying the qualification was necessary before appointing OTD
 Monitoring the licensure certificate of OTDs- to identify any incidents that reflect
the doctors incompetence. It will help identify any restrictions being imposed on
the license
 The application documentation should be more stringent to sought information on
practice history
 Queensland authorities should be strict in detecting any absence of attachment
with the applications.
Under this strategy there is need of monitoring the
 mortality rate if it appeared higher than predicted
 Comparison of aggregated data from the peer group hospitals
 Continues outcome with an EWMA chart- an effective risk adjustment mode for the
analysis. It helps monitor the patient’s outcomes in intensive care unit. This chart helps
identify change in observed compared with predicted mortality over time. It is possible

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using data submitted to the “Australian and New Zealand Intensive Care Society Adult
Patient Database” (Pilcher et al., 2010).
 Incident reporting system in place and instant actions on complaints

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References
Beaupert, F., Carney, T., Chiarella, M., Satchell, C., Walton, M., Bennett, B., & Kelly, P. (2014).
Regulating healthcare complaints: a literature review. International journal of health care
quality assurance, 27(6), 505-518.
Chandler, J. (2017). Bundaberg Hospital Recommendations Are A
Priority. Statements.qld.gov.au. Retrieved 17 August 2017, from
http://statements.qld.gov.au/Statement/Id/41552.
Edwards, M. S., Lawrence, S. A., & Ashkanasy, N. M. (2016). How Perceptions and Emotions
Shaped Employee Silence in the Case of “Dr. Death” at Bundaberg Hospital. In Emotions
and Organizational Governance(pp. 341-379). Emerald Group Publishing Limited.
Jones, A., & Killion, S. (2017). title Clinical governance for Primary Health Networks.
Pilcher, D. V., Hoffman, T., Thomas, C., Ernest, D., & Hart, G. (2010). Risk-adjusted continuous
outcome monitoring with an EWMA chart: could it have detected excess mortality
among intensive care patients at Bundaberg Base Hospital?. Critical Care and
Resuscitation, 12(1), 36.
Terry, D. R., & Lê, Q. (2015). Challenges of working and living in a new cultural environment:
A snapshot of international medical graduates in rural Tasmania. Australian Journal of Rural
Health.

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Terry, D. R., & Lê, Q. (2015). The Anglo-Celtic construction of national identity in Australia
and the acculturation of the ‘other’doctors. International Journal of Innovative
Interdisciplinary Research, 2(4), 62-76.
Watson, J. (2016). Incident management in Bundaberg during the 2013 Queensland
floods. Incident Management in Australasia: Lessons Learnt from Emergency Responses,
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Wilkinson, A., Townsend, K., Graham, T., & Muurlink, O. (2015). Fatal consequences: an
analysis of the failed employee voice system at the Bundaberg Hospital. Asia Pacific
Journal of Human Resources, 53(3), 265-280.
www.phcris.org.au. (2017). Health Systems' Failures & Redemptions: Cases of the Roles of
Clinical Governance and their policy implications. http://www.phcris.org.au. Retrieved
17 August 2017, from
http://www.phcris.org.au/phplib/filedownload.php?file=/conference/2005/presentations/
tuesday/sharp.pdf