Health and Community Services Complaints Commission Report on Investigation of Royal Darwin Hospital Security Arrangements for the protection of Children and Infants Paediatric Ward 5B Volume 1
Tabled paper 163
Tabled Papers for 11th Assembly 2008 - 2012; Tabled Papers; ParliamentNT
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7. takes responsibility for identifying and reporting risks and developing safe practices. 8. A security review of RDH was carried out by an expert hospital safety and security consultant who issued a report in 2007. The Security Manager of DHCS (DHF) was not given a copy even though he requested it. HCSCC enquired of RDH management why he was not given a copy and RDH have offered no explanation. On 31 October after this report was published to RDH and DHF the CEO of DHF advised this Commission that he had finally been given a copy and that he had seen a draft copy. 9. RDH Maternal and Child Health Clinical Risk Management Committee considered security in the Paediatric Ward following the incident. The Committee met on 16th May 2006, 2.5 months after the rape of the infant. It met a further 4 times. It submitted an action plan to the General Manager of RDH in July 2006. At its last recorded meeting on 5 September 2006 there had been no response from the General Manager on the recommendations, particularly with respect to installing CCTV cameras with recording facilities on the Paediatric Ward. There were still no recording cameras on the Paediatric Ward as at June 2008 although a CCTV system had been installed in the kitchen area to deter the pilfering of food. Dr David Ashbridge on 31 October 2008 advised, when responding to a draft of this report, that CCTV cameras were installed in Paediatrics on 25 August 2008. 10. The surveyors from the Australian Council of Health Standards which accredits RDH probably did not receive all relevant information about the incident of 30 March 2006 and what action RDH were taking. Those surveyors on 13 October 2006 were informed by RDH that the patient information pamphlet and admission interview are being reworded to reflect the changes to ward access. There was no verification throughout the investigation that any action had been taken by RDH to implement the recommendations of the review. Neither the report of ACHS nor records of information given to ACHS have been provided to the HCSCC. DHCS (DHF) was invited to provide me with those relevant documents in response to this draft. No response was received on this issue from DHF or RDH. According to the published information of ACHS the accreditation survey commences with a self assessment by the hospital concerned. This Commission specifically requested details and copies of the information provided to the ACHS surveyors but no response was received from either the CEO of the Department or the General Manager of RDH. 11. The governance arrangements at RDH do not promote adequate transparent accountability of the General Manager and the Department of Health and Families for the operation of the hospital. Control of all aspects of the day to day management of RDH rests in the hands of three individuals. This includes staff recruiting, training, security, nursing and medical services, procurement, record keeping, financial accountability and risk management. Such specialist management groups as exist are subordinate to the General Managers authority. The General Manager reports to the Director of Acute Services who reports to the CEO of the Department. I have been unable to find out what role the Royal Darwin Hospital Board has since its last annual report to 30 June 2006. In response to the draft of this report HCSCC received documents about the realignment of the hospitals clinical governance and management structure in October 2007. That restructure still preserves the control by the three above position