Chemotherapy Treatment Error

A question for the Minister for Health - chemotherapy dosing.

The Hon. J.M.A. LENSINK: I refer to the minister's letter to Mr Andrew Knox dated
3 November 2017, in relation to the internal forensic investigation into the chemotherapy dosing
bungle. In that letter, the minister stated that once the disciplinary proceedings have:

…completely concluded, I propose to provide you and the other families involved with the relevant
documents, subject to any legal considerations.

In a letter dated 8 August 2016, the Premier stated that:

It is the government's intention that the findings of the internal forensic investigation also be made public.

The Premier went on to say that:

SA Health intends to provide you and the other families impacted with a copy of this review as soon as
possible after its completion.

My question to the minister is: why has the government extended the delay in the release of the
internal forensic investigation from the date of completion of the report to some future date after all
the disciplinary proceedings have concluded?

The Hon. P. MALINAUSKAS (Minister for Health, Minister for Mental Health and
Substance Abuse): I would like to thank the honourable member for her question. I
acknowledge the member must have a copy of the correspondence that I have written privately to
Mr Knox. That is not a problem within itself, but her having that correspondence and talking to it in
the chamber, I presume, gives me the capacity to be able to talk to it without infringing upon any
confidentiality that Mr Knox may have wanted during this process.

Let me state from the outset some basic principles around my perspective on the
chemotherapy incidents that took place a couple of years ago—I don't recall having had a chance to
be able to provide my thoughts on that—and then I will attempt to directly answer the
Hon. Ms Lensink's question.

Clearly, the events that occurred a couple of years ago in respect to the chemotherapy
dosing errors, principally at the Royal Adelaide Hospital and also the Flinders Medical Centre, are
nothing short of a failure on the part of SA Health. There have clearly been failings within the internal
systems that led to this incident occurring and I think it is important to acknowledge that. It was
acknowledged by my predecessor, and it is an acknowledgement that I maintain. We are not going
to attempt to sugar-coat what clearly has been a failure.

Since that has been acknowledged, I think that puts the government in a strong place to be
able to make sure we commit ourselves to preventing such an incident ever happening again. That
is why the government welcomes the select committee's report that the Hon. Mr McLachlan tabled
yesterday; we welcome that contribution. We see that contribution as occurring in addition but also
in complement to a number of other inquiries that have occurred into this situation, this error, most
of which have been independent.

Of course, we await the outcomes of the current coronial inquest that is being undertaken
almost literally as we speak. There are a number of reviews underway or concluded, and the
government thus far has accepted almost all of the recommendations that have been presented to it
and indeed implemented many of them.

In respect of the more precise question that the Hon. Ms Lensink has asked, I am very keen
as Minister for Health to ensure that the Premier's commitment that he outlined to Mr Knox in his
correspondence, which the Hon. Ms Lensink referred to, is honoured in full in both technicality and
spirit. The investigations that have been undertaken—what we referred to as an internal forensic
investigation that's been led by the Crown Solicitor's Office—haven't been concluded by virtue of the
fact that it hasn't seen its full implementation being realised.

I have to be very careful, not in the interest of the government but in the interests of all
concerned in this matter, including the victims of the chemo dosing errors, to ensure that we don't
prejudice any potential disciplinary proceedings that may or may not be underway. That means that
we have to complete the process in its entirety before said documents can be handed over.

That is undoubtedly a potential source of frustration for those people who would like to
expeditiously be able to see the conclusion of the said investigations, and that is understandable.
Indeed, I find it frustrating—I think we all do—but due process takes time. It is important that we
uphold due process in such a way as we get the right outcome. Once that has been completed, then
the documents will be handed over.

While I instinctively want to go into more detail, I am being very cautious and deliberate in
the words that I am choosing so as not to undermine that process. We have to be very careful that
we don't prejudice an outcome which would be to the detriment of all concerned. That is exactly the
advice that I am acting upon. I am hoping that sooner rather than later that process will be complete
and we can make available the relevant information as is appropriate.