To the Editor: Aspects of the article by Dunbar and his colleagues on the impact of hospital inquiries are disturbing.1

The abstract states, “In the aftermath of the inquiries, common themes included loss of trust in management and among clinical colleagues, and loss of trust from patients and the community”. Rather, the loss of trust in these instances arose from fundamental problems with the culture in the organisations involved. It was this that led to the inquiries.

In the case of King Edward Memorial Hospital (KEMH), the Douglas Inquiry was set up to investigate obstetric and gynaecological services at the hospital between 1990 and 2000, and sought “to identify and assess the deficiencies in the provision of those services, over that period”.2

But when the final report of the Douglas Inquiry was originally published in 2001,2 there was a chapter missing, which was only released under Freedom of Information legislation in December last year. I have seen a copy of this “missing chapter”, courtesy of The West Australian newspaper, which gained its release. It revealed various problems with clinical practices at KEMH, many of which were described as “very unsafe” and which had been going on throughout the 1990s. Nearly 100 cases were covered in this missing chapter, but these were only a small selection of the total adverse outcome events, including several deaths, that occurred over the decade.

And the reason for not releasing this chapter? It was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession — to quote The West Australian, “The current State Government [caved] in to the medical lobby and kept secret the most crucial chapter”.3 Just before it was released, the President of the Australian Medical Association (WA) was still arguing against its release and was quoted as saying, “I can imagine that it would be very painful to these families who were involved and I very much doubt there is anything in it that would serve the public interest by releasing it now”.4 What about accountability? Transparency? Trust?

Dunbar et al state that, “At ... KEMH, there were longstanding problems that had not caused harm”.1 This is an extraordinary comment given that an inquiry was thought necessary, and the clinical problems revealed by this inquiry stretched back over 10 years — during which time no action was taken — until a newly appointed chief executive officer at KEMH, Michael Moodie, blew the whistle.

What concerns me most about Dunbar and colleagues’ article is that in the wake of these inquiries, the authors, who “include the Directors of Medical Services who went into the hospitals following these events” (ie, the inquiries), now seek to argue that such matters are best left to be dealt with internally by “health service providers”.1

We need transparency in such matters. The health service “belongs” to the Australian people — or at least it ought to. It is not the doctors’ health service. These inquiries and the details outlined by Dunbar and colleagues show that, in addressing these sorts of problems, we cannot have trust in most internal reporting systems in hospitals. We cannot trust some of our doctors.

When will they ever learn?

In reply: Mooney makes assertions in his letter and elsewhere1 that cannot go unchallenged.

He is wrong in stating that the “missing chapter” from the Douglas Inquiry report2 “was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession”. To quote the then Minister for Health, “... sections of the [inquiry’s] report were withheld on advice from the Crown Solicitor, mainly for the protection of patients”.3 Detailed reasons for information provided to the inquiry being kept private were published in 2001.4

I stand by my statement that “I very much doubt there is anything in [the missing chapter] that would serve the public interest by releasing it now”. The report on the Douglas Inquiry made 237 recommendations. The reality is that Dr Bill Beresford, who stepped in as Acting Chief Executive Officer (CEO) of King Edward Memorial Hospital (KEMH), did an outstanding job in implementing the report’s recommendations and making a good but under-resourced hospital much better.

Mooney is also wrong to describe Michael Moodie as a whistleblower. He was the CEO of the hospital and accountable for the services it provided. The only person he would be blowing a whistle to was himself, if he failed to act. True, the problems stretched back over 10 years; many of the issues were highlighted in a report released in 1990.5 Among these were the findings that “King Edward is understaffed by 5.2 FTE [full-time equivalent] generalist obstetricians and gynaecologists” and “... the after hours cover is inadequate and potentially unsafe” (Vol. II, p152). I believe it was the failure to act by successive state governments and health ministers, who had the ultimate responsibility for provision of health services, that led to the problems at KEMH.

For at least a decade now, the need to collocate Western Australia’s tertiary obstetric services with adult tertiary services has been advocated, so the increasing proportion of mothers with significant comorbidities, including diabetes, heart disease and substance misuse, can have optimum access to services, including adult intensive care. While this principle appears to have been accepted,6 there has been no indication as yet of its implementation.

Mooney and the community can trust doctors; the lessons from the Douglas Inquiry have been learnt, and its recommendations implemented.

In reply: We are grateful to Mooney for drawing our attention to the “missing chapter” of the Douglas Inquiry report, which came to light after we had submitted our article for publication. Open and fully public inquiries are necessary for all parties involved.1 To the best of our knowledge, the Douglas Inquiry is the most thorough review ever undertaken of clinical standards in an Australian hospital.2 It is difficult to know how other hospitals would have compared over the same period.3

Our article concentrated on how these hospitals recovered, as organisations, to improve patient safety. We called for “open, honest, and timely investigation undertaken within the organisation”, which avoids prolonging the recovery that, paradoxically, can make hospitals less safe.4 In the United Kingdom, the General Medical Council enforces a national system that puts patient safety first and makes covering up for a poorly performing colleague an offence.5,6 It also requires Directors of Medical Services to act in patients’ best interests. Concerns about a colleague’s performance are handled locally, because experience has demonstrated that this works best for patients and doctors.

We would like to see the proposed national registration body for health professionals in Australia make reporting such concerns obligatory.