The Malinauskas Government will completely overhaul the Women’s and Children’s Hospital Cochlear Implant Program, offer impacted families upfront payments and set up a special unit to help them with compensation claims.
This follows an independent review released in full today which found long-standing systemic problems with the service dating back up to 17 years.
All recommendations are being accepted and will be implemented and the Government will be proactively fully supporting families affected.
The report identified 208 children who have received care through the program since 2006. A separate independent clinical review is underway by respected interstate provider NextSense offering reviews to each family.
The hospital has already committed more than $2 million over four years for additional staffing for the service and the Government will fund further costs as the recommendations are implemented. An additional $1.3 million will also be spent on new equipment for the newborn hearing screening program.
Former Australian Chief Medical Officer Professor Chris Baggoley has been appointed to chair an independent committee tasked with overseeing the implementation of all 59 recommendations.
Health Minister Chris Picton ordered the independent systemic review of the program in March, following an internal review identifying as many as 30 children had potential issues with implant mapping at the WCH dating back several years.
A team of interstate experts, led by Principal Consultant Amanda Singleton, was appointed to conduct the review and has now reported its findings and recommendations to SA Health Chief Executive Dr Robyn Lawrence.
The report identified significant gaps including inadequate processes, policies, competency frameworks for staff and a lack of appropriate clinical training in the program dating back many years, and inadequate compliance with incident review policies by WCHN as the under-mapping incidents were initially reviewed.
As an immediate first step in recognising the impact on children and their families, the Government will be offering one-off payments to all families with children who have received cochlear implant mapping at the WCH dating back to 2006.
Those who were under-mapped will receive an initial $50,000, which does not replace a family’s full compensation rights.
Families whose children have not been under-mapped will be entitled to $5,000 to recognise the stress and impact on all families.
The Government is establishing a Special Purpose Family Engagement Unit to provide as much assistance to families as possible to resolve compensation.
In addition, the Government will appoint an independent Family Liaison Unit to act as an advocate for families, supporting them with their questions and helping them determine the best care for their children going forward.
The report not only addresses specific concerns related to the Women’s and Children’s cochlear program but also makes a number of recommendations that have national implications.
Already a similar serious mapping issue has been identified in a Queensland cochlear implant service.
Minister Picton has written to Federal Health Minister Mark Butler to advise of potential implications for other services around the country. The reviewers recommend that minimum standards for cochlear implant mapping be developed at a national level.
The review makes 59 recommendations for the WCH including:
*Boosting staff levels and securing appropriate resourcing for the program to meet current and future demand
*Improving staff training and independent assessment of staff skill levels
*Improving communication with families, including open disclosure discussions
*Reviewing the Universal Newborn Hearing Screening Program to improve the effectiveness and alignment with the national Key Performance Indicators
*Developing minimum standards for implant mapping at a national level
*Strengthened oversight of complex cases and incidents in future
*The establishment of a review committee to implement all recommendations
Action has already been taken following initial observations from the reviewers, including engaging external clinical experts to upskill clinicians, recruiting additional staff including a speech therapist, and strengthened monitoring of the program’s performance.
The reviewers found significant long term problems with the protocols and governance of the program:
“… the Paediatric CI Program did not have clear and up to date procedures for CI mapping, there was no clinical audit process to review outcomes, and no defined program KPIs other than meeting occasions of service activity targets.” – p36
The reviewers highlighted problems with resourcing dating back years:
“There have been no additional resources added to the program to manage the demand through to 2022 despite this issue being flagged in 2018 by audiologists working within the program… The lack of adequate resources, coupled with the ongoing increased demand evident in the numbers was suggestive to the (Review) of a service that was often stretched beyond its capacity to provide safe and comprehensive care.” – p37/38
And the reviewers demonstrated cultural issues affecting care in the service:
“The (Review) was told of a past culture of not being able to disagree with the long-term clinical lead for the CI program and the individual consequences if there was a difference of opinion.” – p36
The reviewers acknowledged “significant amount of work that the team at the WCHN did to determine the scale of the issue and the steps taken to mitigate further risks” however noted concerns regarding adherence by WCHN with clinical review methodology and completion of tasks within appropriate timeframes.
A clinical external review is still underway, with independent interstate provider NextSense assessing individual children’s implants. All families and children are being offered the opportunity to have a full individual review.
The results of this clinical review expected in coming months will provide a more accurate picture of how many of the 208 children since 2006 were under-mapped.
Families are today being sent a letter containing the full report, a summary of findings, and information on how to apply for the payment scheme. A dedicated phone line has also been set up for affected families on (08) 8155 5635.
For more information, including to view the report, visit the SA Health website.
As put by Peter Malinauskas
It is simply not good enough that South Australian children have been failed by a hospital service with significant gaps in cochlear implant mapping procedures and policies dating back nearly two decades.
My heart goes out to affected families and I want them to know that we are adopting all 59 recommendations and putting additional funding in to overhaul the service and ensure severe errors like this are not repeated.
While no amount of money can fix the problems of the past, we recognise the immense stress this has caused families and that’s why we are offering initial upfront payments.
We will also help them every step of the way with full compensation claims.
As put by Chris Picton
I ordered this independent review to make sure we received a full picture of what caused these cochlear implant mapping issues which date back nearly two decades.
I am deeply distressed by these findings and the impact that these long-standing failures, dating up to 17 years, have had on South Australian families.
Over many years children did not receive the appropriate care they needed, and we acknowledge the deep hurt this has caused.
All 59 recommendations will be adopted in full to improve the service and ensure it is giving South Australian children the care they deserve.
There will be no expense or effort spared to ensure that we provide appropriate support for these children affected and the service is fixed so that children can receive safe and appropriate care.
As put by Professor Chris Baggoley
The Government has tasked the committee I will chair to ensure all 59 recommendations are implemented to overhaul this service.
It is important that South Australian families can have confidence again in a vital service for children.
When long-standing systemic failures like this are identified in a health setting, decisive and comprehensive action is required to fix things and that work is already underway.
As put by Women’s and Children’s Hospital Network Governing Board Chair Associate Professor Christine Dennis
As the newly-appointed WCHN Board Chair I am very concerned to learn of these long-standing failures and I will do everything in my power to ensure the required changes and improvements are made.
South Australian children and families deserve better and I want to assure them that we have their interests at the forefront in making these changes.
