Secret hospital deaths: Fatal mistakes hidden


AT a hospital somewhere on Brisbane's southside, a woman arrives for a routine CT scan.

Thirty seconds later, she had a massive cardiac arrest and died - and hospital staff are to blame.

The bungle was just one of dozens of unexpected fatalities flagged in Queensland public hospitals that happen every year but never see the light of day - because the government keeps the information secret.

It means vital health information which would allow Queenslanders to make informed decisions on their health is being kept from them. It means a patient due to give birth or go in for surgery has no ability to check up on the safety record of their local hospital when it comes to fatal clinical incidents.

Not only are the details of unexpected deaths flagged by hospital staff for review treated as off-limits to the public, but Queensland Health even refuses to release up-to-date figures on how many such cases occur.

Patient advocate Beryl Crosby outside Bundaberg Base Hospital. Picture: Paul Beutel
Patient advocate Beryl Crosby outside Bundaberg Base Hospital. Picture: Paul Beutel

The Courier-Mail can only reveal a brief summary of what happened to this woman after a long and expensive search for answers through the state's right to information laws. 

But still, we can't tell you which hospital's mistake caused the woman's death.

The patient, whose identity has not been released, had a known allergy to the iodine-based liquid she has been injected with as part of the procedure. But it had not been noted on her medication chart.

The RTI process is prohibitively expensive and takes months for documents to be released.

For instance, The Courier-Mail was charged $445 to access four pages of basic details of 23 unexpected patient deaths at Metro South - one of 16 Hospital and Health Services regions throughout the state.

RTI officers first quoted $1444 for two years' of incidents - equating to costs of $23,000 if multiplied across the state's 16 health services.

Even then the public is kept in the dark on the name of the hospital where the unexpected death occurred, with the health services redacting that detail from RTI documents in the name of patient privacy.

A redacted clinical incident report relating to the death of a woman at a hospital on Brisbane's southside.
A redacted clinical incident report relating to the death of a woman at a hospital on Brisbane's southside.

The government is so determined to keep hospital deaths a secret that even after releasing the heavily redacted information Queensland Health warned publicity could "cause the community to lose trust in their healthcare".

"If there is a problem in a hospital then people have a right to know but they also need to look at why that hospital is having that issue," patient advocate Beryl Crosby, who has led a right-to-know battle for hospital patients since helping uncover the Dr Jayant Patel scandal in Bundaberg in 2005, said.

"I don't see why this can't be public. People need to know the risks. It's a patient's right to know and it's the public's right to know.

"It's about making informed decisions whether you wanted to go with that particular doctor or that particular hospital with the record that they have.

"People can't make an informed decision before they know what the history is."

The secrecy comes more than five years after Premier Annastacia Palaszczuk rode to a surprise election victory on the promise of a new era of accountability and transparency.

Soon after the 2015 win, Ms Palaszczuk announced new laws to lower the political donation declaration threshold "as part of Labor's sweeping integrity and accountability agenda."

"I think this is a really exciting step forward when it comes to integrity and accountability issues. "No-one is more committed to good, honest Government than me," she then said.

Labor went on to overhaul local government integrity rules and ban developer donations.

But other areas of Government business in Queensland remain cloaked in secrecy.

Today, The Courier-Mail begins its Secret State campaign - a months-long investigation to expose the areas of Government business that remain hidden from public view.

Annastacia Palaszczuk promising transparency and “good, honest government”. File picture
Annastacia Palaszczuk promising transparency and “good, honest government”. File picture

It will examine how secrecy surrounding our schools, courts, law enforcement and our hospitals is undermining the promised brave new age of openness.

In recent weeks, the government has come under increasing scrutiny for failure to release information including refusing to reveal how much state funding schools will be given amid the carve up of $200 million in school spending to create jobs amid the coronavirus.

It is also silent on the status of a probe into Education Department staff found to have falsified student enrolment figures in the school principal recruitment scandal ensnaring former deputy premier Jackie Trad, who was cleared of corruption allegations.

In the meantime, the Palaszczuk Government was busy attempting to push through now-abandoned laws that would make it an offence for journalists to tell voters if political candidates were facing corruption allegations ahead of going to the polls.

Attorney-General Yvette D'Ath had justified the proposed gag on reporting corruption allegations by saying it was a recommendation of the Crime and Corruption Commission.

But Ms D'Ath has ignored another 2018 recommendation of the CCC to close secrecy loopholes in the state's freedom of information laws, the newspaper can reveal.

The Courier-Mail started its investigation by searching for details on the most serious errors in our hospitals, revealing that the details are rarely released outside of intermittent RTI requests by media.

Queensland Health has argued the secrecy is underpinned by the need to protect patient confidentiality and encourage staff to report incidents.

But it does not explain why information cannot be routinely released in a redacted form, with patient and staff names removed.

Details of clinical incidents released for Metro South, for instance, expose common problems that families of elderly patients could act on to help protect their loved ones.

For instance, nine of the 23 incidents resulting in the patient unexpectedly dying in Metro South hospitals in the 12 months to May 2019 involved patients falling over in hospital.

The 23 unexpected deaths were flagged by frontline clinicians prior to any analysis and include cases that were not preventable or may have resulted from an underlying condition.

One patient fell while rushing to the toilet, sustaining a fractured femur and later dying of pneumonia after complications from prolonged bed rest, the documents show.

Another patient to die after a fall that year triggered a review of all falls in the past 12 months resulting in patients being seriously injured or dying.

Another hospital patient died after a fall on the weekend, sustaining multiple rib fractures.

A review found a "mismatch" in staff and patient needs on weekends at the hospital.

"It is noted that there is one consultant rostered who is required to cover all medical and cardiology patients including (emergency department) admissions and phone calls," the review found. "There is currently no capacity for consultant ward rounds on weekends."

Another patient died weeks after tripping on a bed while putting their belongings away.

Queensland Health Director General John Wakefield . (AAP Image/Dan Peled)
Queensland Health Director General John Wakefield . (AAP Image/Dan Peled)

A Queensland Health spokesman said all incidents resulting in an unexpected patient death or permanent harm were reviewed to determine contributing factors and prevention strategies.

"Public hospitals in Queensland are amongst the safest in the world," the spokesman said.

"We have worked hard to develop a patient safety culture that actively encourages staff to report clinical incidents and see these as opportunities to learn and improve."

Clinical incident data was once routinely made public via Queensland Health's Patient Safety Centre, then run by Dr John Wakefield, who was appointed QH's Director-General last year.

The Centre spearheaded a transparency drive initiated by the crisis surrounding Bundaberg Base Hospital surgeon Jayant Patel.

One report for 2005-06 revealed there were 33,226 incidents flagged involving patient harm or near misses in Queensland hospitals, according to media reports at the time.

But the data is no longer regularly released by Queensland Health. It does report the data to the Productivity Commission for inclusion in its reports, but the figures are years old by the time of their release.

In 2019, The Productivity Commission found there were six Queensland events that resulted in death or very serious harm to patients in 2016-17. Two involved patients dying after medication errors.

The Palaszczuk Government has announced a new Queensland Hospitals Insights website reporting on patient safety, such as patient outcome information.

However, it is not planned to include data showing the number of clinical errors or a description of incidents in which patients were harmed or died on the website.

"There are more reliable measures for safety and quality - including accreditation and patient outcome information," a QH spokesman said.

The spokesman said the website has been delayed due to COVID-19 and would be launched in April 2021. It would include data from public and private hospitals.

At the moment, private hospitals are not required to report clinical incidents to the Government.

Originally published as Secret state: Details of fatal health bungles hidden