Few who watched the episode of 60 Minutes in September 2020 where journalists Liz Hayes and Jamelle Wells told of the death of their fathers in the rural health system can forget their tragic stories.
That episode, and the accompanying report in the Sydney Morning Herald, led to the NSW parliamentary Inquiry into health outcomes and access to health and hospital services in rural, regional and remote New South Wales.
The inquiry is underway, with a hearing being held in Taree on Wednesday, June 16. The hearing will be webcast live at www.parliament.nsw.gov.au/Pages/webcasts.aspx from 3pm.
Witnesses speaking to the inquiry are:
- Eddie Wood, president, Manning Great Lakes Community Health Action Group
- Bree Katsamangos, convenor, Mid Coast 4 Kids
- Melissa Foster, Aboriginal project worker and playgroup coordinator - Child Care Services Taree and Districts Inc.
- Judy Hollingworth, founder and deputy chair, Manning Valley Push for Palliative
- Robyn Jenkins, secretary, Manning Valley Push for Palliative
- Dr Nigel Roberts
- Dr Simon Holliday
- Dr Seshasayee Naramsimhan, visiting Medical Officer, acute care physician and cardiologist, Department of Medicine, Manning Base Hospital
- Alan Tickle
- Marion Hosking OAM
- Michael DiRienzo, chief executive, Hunter New England Local Health District (HNELHD)
- Dr Peter Choi, director of Medical Services, John Hunter Hospital, HNELHD
Hundreds of written submissions were put forward to the inquiry. Below we have included some details from six submissions, in dot point form, from journalist Jamelle Wells, registered nurse Vicki Morrison, Dr Simon Holliday, John Hunter Hospital Hunter New England Health, and journalist Liz Hayes.
- Jamelle's father Allan Wells, 85yo from Cobar, fell and broke his hip in his house.
- Flown from Cobar to Dubbo Base for surgery on September 26, 2019.
- Private patient, billed $12,000 by Dubbo Base, but "doctor whose name was written on his bed and medical records did not perform the surgery".
- Nursing Unit Manager tried to discharge him while still very unwell. Hours later he "went into cardiac arrest with a pulmonary embolism and deep vein thrombosis in both legs, after the hospital stopped giving him post-surgery anti-clotting medication"
- "Doctors advised against resuscitation because of (his) age despite being aware of his full resuscitation plan. At the family's insistence he was put on life support and pulled through, with full mental capacity."
- No pain relief soon after surgery.
- Unsupervised junior doctor "repeatedly failed to insert a feeding tube in his nose" which was traumatic for Alan.
- Alan was told by a staff member that he might have his hands tied to his bed to stop him pulling his tubes out. Jamelle says Alan was too weak to pull tubes out, and had full mental capacity.
- On October 6 Alan was moved from intensive care to a ward, but because it was a weekend no dietician was available to assess whether he could swallow after being intubated. Hospital manager told Jamelle they "couldn't afford" to roster someone on a weekend and her father would "have to wait."
- "It was heartbreaking hearing him beg for food and water for three days, after his trauma of a cardiac arrest and being on life support."
- Alan was covered in bruises and denied pain relief on one occasion because a nurse said the ward had run out of morphine and panadol.
- "After a doctor failed to seek family consent before ticking 'not for clinical reviews' in a revised resuscitation plan, doctors were no longer coming to see my father. We had to fight to have a clinical review by doctors reinstated."
- Staff incorrectly wrote 'dementia' in Alan's file because he was hard of hearing. He passed all hospital mental acuity tests with near perfect scores.
- October 24, 2019 Alan was suddenly discharged from Dubbo and transferred to Cobar Hospital, still in pain and vomiting, by road ambulance, a four hour trip, in 40 degree heat.
- "One nurse refused Dad's last minute request to send him to Dubbo Private Hospital where he wanted to recuperate."
- "I later discovered Dubbo Base Hospital doctors had written 'not to be returned' on my father's discharge papers. They did not want to treat him anymore, even though he had a legal right to seek treatment at any time."
- November 4, 2019 visiting aged care assessor said Alan should stay in Cobar Hospital another week as he was too unwell to be moved. When the assessor left, Cobar Hospital staff told them he could not stay and he was to go to the local nursing home.
- Alan was taken to the nursing home on Melbourne Cup day. He died five days later.
- Jamelle says the Western NSW Local Health District (WNSWLHD) had lacked transparency. When questioned by the Sydney Morning Herald a spokesperson said the hospital never had a shortage of paracetamol or morphine and staff were always available on long weekends and public holidays to assess swallowing following intubation.
- WNSWLHD was directed by the Health Minister to conduct a review (after the story was published in the SMH).
- WNSWLHD scheduled a meeting with Jamelle one working day before the report was due to be given to the Minister. She was assured the deadline would be extended to include her serious concerns in the report. However a week later she was told her concerns were excluded from the report because 'it was not possible to delay the submission of the report'.
- Jamelle recently received a copy of the report. She said it had errors - including the type of surgery Alan had.
- Dubbo Base Hospital overcharged for her father's medical records - $600 when the rate for pensioner's records is $30. Records were missing information and had the wrong surgeon's name. They breached patient privacy as another person's records were mixed in with Alan's. Refund of $600 for overcharge of reports only offered after the story on air 60 Minutes. They also refunded $900 to another woman from Broken Hill for her late father's medical records after she said she also was going to 60 Minutes. That woman's father's death is being investigated by the coroner.
- "There are systemic patient care problems and a lack of compassion in Dubbo and Cobar hospitals which are run by the WNSWLHD, especially with treatment for the elderly."
Vicki Morrison - submission one
- A registered nurse for 45 years with her performance never called into question.
- She worked the last 17 years with Taree Aged Care Assessment Team (ACAT), the last 14 of those years as a Clinical Nurse Consultant Psychogeriatrics, working closely with the psychogeriatrician
- Psychogeriatrician was FIFO one day per month.
- "I am grossly disappointed with the lack of attention to the Hunter New England Health District (HNELHD) CORE principles... The service I have supported and provided has been ridiculed, negated, criticised and declared non-viable and of low priority."
- Psychogeriatrics - frequently dementia and mental health issues combined.
- December 2019 - the specialist doctor left, after resigning in September 2019 to give plenty of notice. The resignation was sent to Area Director of HNELHD Mental Health Services as ACAT had no manager. A telehealth meeting was held with incoming ACAT acting manager to discuss service and ongoing care and management of clients.
- In January 2020 Vicki met with acting manager ACAT who told her to send letters to all GPs to let them know the specialist was leaving and service was unavailable for the time being.
- On February 27, 2020 in a meeting with the Mental Health Service Manager she was informed that all funding that Aged Care had for a psychogeriatrician going to Mental Health and they would employ the person. Later another Mental Health employee said this wasn't going to happen.
- Around the same time Vicki was told the psychogeriatrician position would not be filled and she was told repeatedly that the service was no longer a priority for medical management to consider.
- A meeting with Medical Services Manning Base Hospital was held to decide the future of psychogeriatric services - Vicki was not included and never informed of the outcome. The psychogeriatric service was not represented at that meeting.
- Vicki repeatedly asked her manager for information and guidelines on service to be provided as the service had been dismantled. She has had no replies to date.
- On April 8, she met with the manager, who questioned Vicki's clinical practice and threatened her with performance management.
- March 25 meeting with Union Staff Consultative Committee. The general manager was present. Vickii was informed Taree ACAT had never had a psychogeriatrician or funding - it was all under Mental Health. Vicki says the general manager said no change was warranted because geriatricians (not specialising in psychiatry) were managing patients, so no psychogeriatrician was needed.
- Vicki was called to a meeting and it was "nothing short of an attack on why I hadn't completed service setup." Still she had received no input despite her frequent requests.
- "I am disgusted by the lack of attention to the CORE principles."
Vicki Morrison - submission two
- Vicki says the psychogeriatric service was maintained until Manning Great Lakes became part of HNEHLD. "Since that time (the service) has been gradually dismantled and fragmented to the point now where it hardly functions at all."
- The Myall Lakes electorate has the oldest aged population in NSW, and diagnoses is rising in tune with increased ageing population.
- The CADE unit (Riverview Lodge in Wingham) was removed from Aged Care and transferred to Mental Health Services and called TBASIS unit - staffing levels dropped, medical coverage almost non-existent. Elderly people with comorbidities were housed 12kms from hospital.
- Attempts made to negotiate with the Manning Hospital Emergency Department re medical assessments and transfers back to the unit at Wingham. "The TBASIS staff were met with blocks." Management of Mental Health Services in Newcastle frequently told them 'there was no money'. The unit eventually closed - it had provided services from Newcastle to Queensland
- "The closure of the TBASIS was done with stealth with negotiations being kept away from staff until the last possible moment when Human Resources swooped and gave staff their marching orders."
- Staff were assured clients would be admitted to a similar unit in Newcastle. Vicki says there is always a long wait for Newcastle beds.
- Now, the current psychogeriatric service consists of a Dementia Support registered nurse 12 days a week, a clinical nurse consultant two days a week with no psychogeriatrician since December 2019.
Dr Simon Holliday
Experiences of GPs in rural practice
- Difficulties of recruiting GPs to regional and rural areas. "Already over-stretched rural doctors find it near-impossible to recruit Australian-trained colleagues with appropriate skills."
- When recruiting a GP he is flooded with overseas applicants - who may or may not have passed one of two parts of the AMC exams. "Not a single one of these will be recruitable within several years."
- Recruitment agencies charge $14,000 to $25,000 for a successful placement.
- He rarely hears from Australian-trained GPs when recruiting. "The rural Doctors Association of Australia recently estimated that fewer than five per cent Australian-trained doctors choose to practice rurally."
- On recruiting International Medical Graduates (IMGs) Dr Holliday says "there is an urgent need for some communication between the different state and federal regulating bodies involved in this process." It is not only difficult for GPs trying to recruit, but for those wanting to be recruited.
- IMGs require "onerous levels of support from their supervisor".
- Registrars need a lot of time off for study and exams, and don't want to work too remotely so they are not too far from educators.
- "Our Manning Hospital now does not accept major trauma which is re-routed to Port Macquarie. This would cause many orthopaedic surgeons or registrars to choose to leave the area or avoid coming here. Few would wish to work in a hospital that did not have a suitable caseload or equipment befitting their hard-earned and well-remunerated skills"
- Some of the barriers for rural doctors: being on call every night for hospital, hard to access or cover the cost of a locum, patients have to wait weeks to see a GP, there is a large aged population in rural communities, a high turnover of GPs. Overstretched GPs are more likely to cut corners or make mistakes.
- There is a steady decline in investment in rural hospital infrastructure across NSW.
- Some GPs report "a toxic and adversarial attitude of the hospital ... putting cost ahead of community..."
- In some areas holiday seasons increase workloads as the population may swell four-fold.
- There No work/life balance
- Many rural areas are lower socio-economic areas, and bulk billing doesn't generate "income significantly above operating costs".
- Dr Holliday says there is a lack of collaborative planning and leadership. "In the Manning Valley, we have the federal electorate with the oldest population and yet only have one part-time community geriatrician and one full-time geriatrician who additionally has to take up a general physician on-call rotation at Manning Hospital." ... "Here in Australia's oldest electorate, the waiting time to see a local geriatrician (triaged) is seven months."
John Hunter Hospital
- John Hunter Hospital (JHH) is the busiest trauma service in NSW.
- It is the only combined adult and paediatric trauma centre in NSW and the only Major Trauma Service outside Sydney.
- Thirty-nine per cent of all severely injured trauma patients come from rural areas to JHH..
- Case fatality rates remain the highest in Rural Trauma Services
- There are prolonged scene times and transfer times because of location.
- There are long delays until reaching definitive care compared to metropolitan areas.
- Over a quarter of JHH patients (26.5%) are transferred from referral hospitals.
- There is a lack of adequate intensive care unit capacity - rural patients often need to bypass John Hunter and travel to Sydney, resulting in further delays, necessitating the use of more resources and inconvenience to families.
- Long rehabilitation times - large distances needing to be covered for multiple outpatient appointments.
- JHH is the busiest in the state and second busiest nationally for elderly hip fractures.
- People transferred to JHH on average adding on another 48 hours to access operating theatre.
- "Despite our best efforts there are still significant delays to definite care for our rural and remote patients and this impacts negatively on their outcomes...
- "... the system is strained and at risk of collapse that would further impact on our rural and remote patients."
- Liz's father Bryan Ryan was admitted to Manning Base Hospital (MBH) in August 2019 and diagnosed with pneumonia. Had a webster pack with him. However higher doses than he would normally have of his medication were given to him three times that night. He was overdosed twice the amount with one drug which slowed his heart to a concerning level. MBH conducted an investigation and concluded it was the result of human error.
- Bryan was transferred to the Mayo Private Hospital in Taree via ambulance to recuperate but did not have a medical discharge summary. He did have a full list of prescribed medications. The doctor missed Bryan's blood thinner - it wasn't written down. (Blood thinner was for atrial fibrillation and crucial to prevent him having strokes.). Bryan missed his stroke medication for eight days because of the mistake, and no other nurse or doctor picked it up.
- Then he suffered a catastrophic stroke.
- The error was only picked up when they went to MBH where he was taken for emergency treatment, as the error was written in the hospital notes. The Mayo doctor, who had gone home, later came to the emergency department at MBH to advise of medication error.
- An investigation again cited human error.
- On the night of Bryan's stroke, The Mayo only had one doctor rostered on - they are a 79 bed hospital.
- "During our family meeting with hospital management, it was explained that this situation of just one doctor to cover all patients, was because 'that's the case in most country hospitals'.
- "Distance does mean disadvantage."
- "From my own research it is clear medical staff at many hospitals are expected to dispense an extraordinary range of services without proper facilities or support."
- "Nursing staff often left to hold the fort ... Paramedics are spending more time on the road transferring patients to other hospitals where there are doctors, leaving the towns they're supposed to cover without an ambulance service.
- Health workers have told Liz Hayes they are fearful for their patients because of a 'substandard health system' but are too afraid to speak out for fear of punishment.
- "My experience as a journalist is that there is often a defensive reaction to media exposure..
- "It is to be remembered that this is the peoples' health system. It is taxpayers' money that pays for the jobs of many of those who seek to pull down the blinds. Transparency is essential."
- "It is outrageous that nursing staff run off their feet, tell of having to rely on the cook in some rural hospitals, to help look after patients."
- "It's clear governments and their health departments need to nail down how to attract doctors to live and work in rural communities. And it's essential for rural communities with specific needs to receive help, whether it be mental health services, palliative care or, as in the Manning-Great Lakes region, cardiac care where heart issues are amongst the worst in the state."