Lessons for all in system failures at Djerriwarrh

16 Feb 2016

Australia’s health practitioner regulator says there are lessons for everyone in the tragedy at the Djerriwarrh Health Service and that AHPRA is doing its part to address the system failures that let patients down.

Employers, hospitals, health practitioners, AHPRA and the National Boards all have important roles to play in keeping patients safe, said AHPRA CEO Martin Fletcher.

‘Djerriwarrh showed there were gaps in the system that was designed to keep people safe and AHPRA is doing our part to address the problems this tragedy revealed,’ Mr Fletcher said.

‘We have looked at how we could have done better with what we knew, who we could have shared information with, and what we didn’t know, but should have been told,’ he said.

AHPRA is not able to discuss any current or historical cases further, because our investigations into individual registered health practitioners who worked at the Djeriwarrh Health Service are continuing.

‘There is nothing more important than making sure these investigations continue to be thorough and fair,’ he said.

In October 2015, AHPRA made a statement about an investigation into a complaint about one of the long serving doctors at the health service. The investigation related to a single case and the follow-up care provided to a mother after birth.

When managing that complaint, AHPRA and the Boards were not advised of abnormally high perinatal mortality rates at the health service or wider concerns about the quality of obstetric or midwifery care provided at the Djerriwarrh Health Service.

‘It is clearly an issue that we had one piece of information but not the whole picture. Other agencies had information we didn’t know about. We all have to find better ways of sharing information, within the law, to better protect patients,’ he said.

‘If we are not told about concerns, we are not able to do our job as a regulator to manage possible risk to patients,’ Mr Fletcher said.

Already, AHPRA requires all practitioners who are subject to regulatory action to disclose their employers’ details, so we can make sure the right people know when regulatory scrutiny is being applied.

AHPRA has information sharing services for employers so they can stay up to date with the registration status of all their employees.

‘As regulators, we are not advised of civil action against registered health practitioners. We will be working with professional indemnity insurers and other agencies to address barriers to information sharing, within the law,’ he said.

He said since Djerriwarrh, AHPRA had committed to:

• More comprehensive risk assessment of all notifications, so high risk cases are identified early 
• Specialised management of high risk cases, with targeted investigative strategies matched to the level of risk 
• Early identification and resolution of low risk matters, so these can be closed quickly in the best interests of the person making the complaint and the practitioner and 
• Use the powers in the National Law to promote information sharing between agencies, within the law.

By law, the core focus of AHPRA and the National Boards is to protect the public and manage risk to patients.

‘This commitment guides what we do. It is clear in our regulatory principles and reflected in the fact that there are community and practitioner members of all decision making Boards in the National Scheme,’ he said.

AHPRA actively promotes the register of practitioners and encourages all members of the community to use it to check the current registration status of their health practitioners.

AHPRA has established a community reference group to advise on ways to make our processes more consumer friendly and how to improve our processes and better inform the public about what we do.

‘We recognise that we have more work to do to better communicate that public safety is our priority,’ he said.

Media enquiries: (03) 8708 9200

Download a PDF of this Media statement - AHPRA says lessons for all in systems failure at Djerriwarrh - 16 February 2016 (72.2 KB,PDF)