Findings of Cull report And MOH Response
Findings of the Cull report and Ministry of Health response:
The inquiry team drew eight lessons from the current inquiry:
1. All health professionals, especially senior practitioners working at an expert level, but isolated from others of the same level of equal competence, must have access to adequate peer review.
2. Because parents of the infants in the inquiry were largely unaware of the disability from pre-term birth, particular care needs to be taken with parents of pre-term infants to ensure that they have been informed of the risk of adverse consequences, in clear and understandable language.
3. Detailed record keeping at National Womens Hospital was excellent and permitted the inquiry team to come to its conclusions and recommendations. Good, detailed, clinical record keeping is recommended as good practice for all health professionals.
4. The issues of consent for complex and prolonged admission with consequent multiple treatments, particularly in a neo-natal intensive care unit needs special attention. The inquiry team, on the advice of Sandra Coney, recommended a working a party comprising consumers, clinicians and members of multi-disciplinary teams should to provide a standard approach to consent.
5. Parental consent for staff training using the infants at National Womens Hospital was not sought. Parents should have been advised that the Hospital was a training hospital, that the position and role of the staff should have been explained and that the parents had a right to know the experience of the person treating their baby. This needs to be addressed nationally.
6. One of the issues identified is whether the research outcomes from an internal clinical audit should have been sent to the Ethical Committee for approval before being published. Whether the intention to publish means that it is research and no longer an internal audit needs to be clarified in the National Standards for Ethics Committees.
7. The referral of consumers, such as the parents in this inquiry, to a Patient Advocacy Service, would have been of assistance to the parents, to provide a liaison between the parents and the neo-natal unit and facilitate the disclosure of information. All health professionals should refer consumers to the Patient Advocacy Service, to assist in any outstanding inquiries and needs, and the inquiry recommended that Patient Advocacy Services be strengthened.
8. The inquiry recommended ongoing neo-natal audit and research is to be encouraged and supported. National Women's was commended for the steps it took to reseach and publicise its findings of possible links between the treatment and the brain lesion and for the steps it took to inform parents of children affected by the treatment.
The Ministry of Health intends to address the eight lessons to be learnt in the following way:
Peer review. The issue of peer review and competency is enshrined in the current Medical Practitioners Act, 1995, but not in the legislation surrounding other Health Occupational Regulatory Groups. This issue could be addressed in the current Health Occupation Registration Acts Amendment Bill designed to corporatise the Boards (which is currently awaiting consideration by the Committee of the whole House), but this would require a Supplementary Order Paper or return to Select Committee. This is however outside the scope of the Bill. In the review of occupational regulation conducted by the Ministry in 1997, the Ministry concluded that the introduction of competency should be included in any future legislation. The inclusion of competency is supported by the health professions. Competency was not considered in the current Health Occupation Registration Acts Amendment Bill because this was considered to be a wider issue than corporatising the Boards. It was to be considered along with wider issues such as registration and establishing separate disciplinary tribunals. In the meantime, the Director General is writing to all occupational boards and councils, with a copy of the inquiry, to draw their attention for the need for peer review and ongoing competency provision.
2. Information for neo-natal intensive care units and 4) informed consent in neo-natal intensive care units. The Ministry of Health will facilitate a working party comprising consumers, clinicians and members of multi-disciplinary teams to provide a standard approach for information and consent.
Detailed record keeping. In the Director General’s letter to Occupational Boards, the Director General is requesting that all health professionals will be advised of the need for good record keeping.
4. See 2 above.
5. Consent for training. The Director General is writing to the Health and Disability Commissioner with a copy of the report to advise her of the need for consistent guidelines in this matter. This appears to a wide and generic issue for health professionals as to how they inform patients on their competency.
6. Clarification of publication of internal audits and Ethics Committee approval. This matter is referred to the working party reviewing the National Standards for Ethics Committee which meets on the 7th July 1999. In addition, this matter will be considered in the current Ministry of Health review of part VI (Quality Assurance provisions), of the Medical Practitioners Act 1995. There will be a question whether protection of information gathered as part of a quality assurance programme actually contributes to improved the practices and competency of medical practitioners.
7. Patient Advocacy Services. In the Director General?s letter to the Health and Disability Commissioner she will advise her of the need to encourage the use of Patient Advocacy Services.
8. Research in Neonatology. The Director General is writing to the board of the Health Research Council with a copy of the report advising them of the need for research in neonatology when addressing their priorities for purchasing health research in New Zealand.
6 July 1999
Parents response to the report of inquiry into chest physiotherapy treatment of neonates at National Womens Hospital.
Counsel for the families, Mr Peter Edwards, said they were glad the report was finally published. It had validated the finding of medical error, ie negligence, by the Medical Misadventure Committee of ACC and justified the concerns expressed by parents of the babies over many years.
It was no consolation for the parents to have their worst fears realised in learning that the chest physiotherapy treatment their babies received at National Womens Hospital was so out of line with that practiced at other neonatal units and so harsh that it probably caused their babies brains to hit the inside of their skulls, thus causing damage to the brain and, in some cases, death.
The report has found that the chest percussion physiotherapy as applied at National Womens Hospital was of greater vigour and greater duration than at other hospitals. It also found the stability limits, that is the oxygen level in the blood which is the life support of the babies, were allowed to vary and deteriorate to a greater degree than at other hospitals. The report found that no parents consented to the treatment or to the training of nurses on their babies.
A number of parents had expressed concern when first seeing the treatment performed but were assured by the health professionals attending that it was safe and were even told that 'the babies enjoyed it (the treatment)'. Yet the treatment caused brain damage and death?
The view that the treatment was fundamentally flawed is supported by the call from Dr Poutasi for Auckland Healthcare to conduct a 'lookback programme' for the period of 1985 - April 1993, he said. This is to see whether the cases studied at the inquiry are the only cases of brain damage that occurred as a result of the treatment.
Mr Edwards said it was not good enough to suggest that the health professionals were solely motivated by their desire to do their best for these pre-term babies. Many things can be done for the right reasons and the person doing them may sincerely believe in that which they are doing. When the outcome is so devastating, this is inadequate as a defence, and in any case, the health professionals concerned failed to put in place checks and balances which could have prevented the tragedy.
The report identified that the health professional, who introduced the treatment and was responsible for training others in the technique, was not applying the technique properly. It further said that 'the staff member was not aware that the application was not done correctly or was of greater vigour than elsewhere'.
Mr Edwards also expressed concern that letters supplied by the health professionals and National Womens Hospital?s management to ACC?s Medical Misadventure Committee had not identified the first known case as September 1992 but had advised that the first case occurred in May and June of 1993. This action was misleading and it drew the focus of attention more closely to the change in the practice of chest physiotherapy at National Womens Hospital rather than to the treatment itself. Such mis-information raises the question of why? Likewise what happened to the physiotherapy protocol sent by Dunedin Hospital which contained a warning concerning possible intracranial damage.
National Womens Hospital, it?s management and the health professionals involved must accept responsibility for this catastrophic tragedy and be held accountable. The emotional, physical and financial costs to the families are considerable and the long term impact of these costs cannot be ignored. These families and their children are deserving of compensation and we intend for these matters to be addressed, Mr Edwards said.
Not all the parents involved had received the final report as some were away so Mr Edwards has requested that all contact be directed to his office and the family?s privacy be respected.
There is yet alot of unfinished
business to attend to, he