nurses

Statement regarding off-protocol dosing of Carboplatin

April 2016

The hospital apologises deeply and unreservedly to the patients and families affected by this matter. We are sorry you’ve had to go through this; and we are sorry for letting you down in this way.

In fact, we apologise to all our cancer patients at the Sydney hospital – including those not directly affected or involved in the dosage issue – because many would still have found this matter a source of anxiety and concern.

Finally, we apologise to the public, who rightfully have high expectations of the hospitals that care for them and their loved ones.

We now have two priorities: to support the patients affected and their families, and to make sure this doesn’t happen again.

We have already begun contacting all the patients involved and their families – as we’ve done previously – to update them on the Cancer Institute’s review and its findings.

Importantly, we have engaged Professor Robert Thomas OAM – Chief Advisor on Cancer to the Victorian Government – to oversee the hospital’s implementation of the review’s recommendations.

Professor Thomas is one of Australia’s most respected cancer surgeons. He will provide a public report on our progress at three, six and 12 months, so we can be judged on our performance.

It’s clear we have not lived up to the high standards we set ourselves.

We failed to appreciate the seriousness of the situation: early questions about the doctor’s dosage practice should have led to a formal examination.

Both our internal and external inquiries should have been more comprehensive and completed more quickly in order to begin talking with patients and their families sooner and with greater accuracy.   

And while very early on we made the decision we wouldn’t contact patients about this matter until we had all the information at hand so as not to cause unnecessary distress, we now recognise this was a mistake and accept the review’s findings that we should have communicated with patients earlier.

We are working hard to ensure similar problems do not occur again.

During the course of the review we provided approximately 1400 separate documents to the review team. Many of our staff were interviewed or provided statements.

For over the past 18 months we’ve been making changes – independent of this matter – to strengthen governance within the hospital.

We have put in place a world-standard cancer electronic medication system that automatically updates new dosage protocols. If any clinician wants to prescribe medication outside the guidelines they must submit their request and explain their reasoning. Regular clinical audits will also ensure this is occurring.

Already, all cancer patients at St Vincent’s are treated and overseen by a multi-disciplinary team as per the review’s Statewide recommendations.

The hospital has established a new peak clinical governance committee – known as the Clinical Council – which brings together senior clinicians, consumers and executives in the planning and operations of St Vincent’s. And we have established a Cancer Services Advisory Council to oversee the implementation of the hospital’s new Cancer Services Plan.

We have also recently appointed a number of consumer advocates to key governance committees and departments, including the Clinical Governance Committee for Cancer Services.

Finally, in December 2015, our new head of Medical Oncology – a world-leader in his field – commenced with the hospital.

If you have concerns about the treatment you or a loved one has received or require further information relating to the off-dosing of Carboplatin, please call our toll free line 1800 901 922. The 1800 number will be operational from 8.30am - 8.30pm.