Dr John Wakefield.
Dr John Wakefield.

Toddler's death shows problems

THE investigation into the death of Emerald toddler Ryan Saunders revealed a number of areas Queensland Health could improve.

Called to give evidence at the inquest in Rockhampton last week, director of patient safety, quality improvement services Dr John Wakefield told the inquest the 16 recommendations arising from the investigation were initially hindered because the report into the two-year-old's death was not published.

"It was a frustration of mine that all recommendations were immediately accepted and given for implementation, without due consideration of merit or usability," he said.

"I think in relation to the stakeholders and the people who actually have to do the work, it's much easier to convince people they are investing in a major change on their business when they can understand the major reason of why."

He said the early problems had been overcome and reported 13 recommendations had been completed.

The enactment of the AusCare system throughout Queensland Health, which will enforce a trigger benchmark figure on a patient's medical history, will ensure any test that the multi-million dollar system deems necessary for the patient's wellbeing will be completed.

Dr Wakefield said it meant "no test can go missing or disappear", although he was unable to give a time when the system would come into full effect.

The Child Early Warning Tool is a world-leading system, which maps and graphs a patient's medical history and visually presents doctors and nurses with results, so as to prompt attention and treatment, as required.

It operates on a numerical score system: the higher the number, the more urgent the attention needed. It is an ongoing development throughout Queensland Health.

It was also recommended the public health system implement an escalation report for pathology reports, which automatically indicated variations in a patient.

Together with the Child Early Warning Tool system, quarterly reports would be submitted to the Health Quality and Complaints Commission, until the new operating systems were fully enacted.

The recommendations limit the possibility of human error but Dr Wakefield was still cautious, saying if the systems had been in place in 2007, when Ryan was admitted to hospital, it may not have changed the tragic outcome.

"We're very attuned to whether a recommendation would have prevented or altered the specific course of events and I think if you analyse the recommendations in that way, I don't believe they all would have had an impact," he said.

Some key recommendations:

Queensland Emergency System Clinical Retrieval staff provided adequate training throughout Queensland. Immediate access to training material and medical journals should be available at all times.

Queensland Health to review existing policies and processes, to ensure rural and regional officers receive all relevant training, help and support.

QH to review the accessibility of educational tools and guidelines and to ensure staff have up to date medical research findings.

QH to develop, implement and educate staff on formal on-call rosters in radiology at the Rockhampton Base Hospital.

QH to implement, monitor and report all formal process of shift handovers between staff at the Rockhampton Base Hospital.

QH to review nursing practices that may have impacted on the care of patients. In part refers to the recommendation from nurses they can determine if a patient requires pain medication.

QH to undertake a review of the pediatric team at the Rockhampton Base Hospital and report all actions for improvement to the Health Quality and Complaints Commission.

The Medical Board of Queensland to consider whether further investigations are required into the management and supervision of Ryan Saunders by director of pediatrics at Rockhampton Hospital Dr Peter Roper.

QH to implement and evaluate recommendations one, three and four of the root cause analysis.

QLD Emergency Medical System Co-ordination Centre to review and improve its sentinel event review processes and provide adequate training to staff performing event reviews.


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