This report details the Office of the Health Ombudsman’s (OHO) investigation into the death of Arkadiusz ‘Arthur’ Tumanis at Cairns Hospital’s mental health unit in 2015.

In April 2015 Arthur presented to the emergency department on two occasions within 24 hours. As no physical cause of Arthur’s pain could be identified and he had a history of presenting with physical symptoms when he was experiencing an acute change in his mental health, Arthur was admitted to the mental health unit.

Despite intervention aimed at reducing his agitation, Arthur continued to complain of significant pain. Two days after his admission, Arthur was found unresponsive near the nurses’ station and was not able to be resuscitated. Arthur’s death was found to be a result of peritonitis due to an undetected perforated ulcer.

Arthur has been identified here and in the published report with the consent of his father, the complainant.

Scope of investigation

Throughout the OHO’s investigation, a number of concurrent investigations were undertaken by other agencies including the Coroner’s Court of Queensland. The OHO sought to avoid duplication and potential cross-contamination of evidence throughout the investigation.

The CHHHS also conducted a Root Cause Analysis of the incident; an RCA is an internationally recognised approach used to analyse serious clinical incidents in the provision of healthcare that result in permanent harm or unexpected death. The purpose of an RCA is to improve patient safety by identifying weaknesses in healthcare systems and processes, and make recommendations to prevent an occurrence of a similar event. An RCA does not seek to determine liability or apportion blame to individuals. The office determined the RCA report represented a thorough and comprehensive analysis, and was satisfied the report’s findings and recommendations for improvement could be relied upon to address the issues identified in the RCA.

Consequently, the OHO’s investigation focused on the implementation status of the RCA report’s ten recommendations and five ‘lessons learnt’ recommendations. It also considered any additional system or process issues that have arisen as a result of Arthur’s death.

Findings

The investigation identified a number of issues related to the CHHHS’s governance systems and the impact of inadequate systems on patient health outcomes—in particular patients with complex care needs.

Issue 1—Adequacy of RCA recommendation implementation

The office conducted a thorough review of information and evidence provided by CHHHS to assess the effectiveness of the CHHHS’s actions and activities in implementing the RCA report recommendations.

Health Ombudsman’s finding:

All recommendations arising from the RCA report are determined to be ‘fully implemented’ at CHHHS. Through the implementation of the recommendations, the CHHHS has introduced effective system and process improvements that will prevent a similar incident from occurring at the Cairns Hospital in future.

Issue 2—Dual diagnosis

Dual diagnosis covers a wide range of presentations and conditions and is defined by Queensland Health as the co-occurrence of two or more problems or disorders, one of which is a mental health problem and at least one of which relates to the use of alcohol and other drugs; a person with a dual diagnosis is someone who has a mental health problem and a substance use problem.

During the office’s Cairns Hospital site visit, discussions with clinical staff repeatedly raised the complexities and challenges associated with the provision of quality, evidence-based care and treatment for patients with a dual diagnosis. The complainant also raised concerns of staff bias against his son due to his history of drug use and his mental health history.

Health Ombudsman’s finding:

Arthur’s case highlights the importance of quality, holistic care to patient outcomes and the need to treat all aspects of an individual’s health—including their physical health—throughout the course of their admission.

My office has worked closely with CHHHS to determine that appropriate changes have been made by the hospital and health service, significantly improving the overall quality of the health care services provided to patients in the mental health unit. I encourage CHHHS to continue to review and evaluate changes that have been implemented to improve the quality of services and treatment for patients with complex care needs, such as dual diagnosis.

Issue 3—Clinical incident management and analysis

Despite the intentions and best efforts of health services and health care workers, adverse events and patient harm can and does occur. To reduce the incidence of preventable patient harm, clinical incidents need to be effectively managed; this includes applying principles of patient centred care, safe and just culture, consistency and fairness, a team approach, and confidentiality.

Health Ombudsman’s finding:

Since Arthur’s death, the CHHHS has introduced a new incident management procedure and revised the management of incident analysis processes. My office has reviewed the timeframes of eight RCA reports conducted by CHHHS since 2016 and can confirm that all reports have been completed within the stipulated 90 day timeframe. I encourage CHHHS to continue to conduct regular reviews and evaluations of clinical incident management processes to ensure clinical incident analysis is commenced and conducted in a timely manner.

Issue 4—Open disclosure

Open disclosure describes an ongoing process of open discussion between an organisation and the patient, and/or their family and carers, about adverse events that resulted in harm to the patient while receiving health care. It is a mandatory accreditation requirement that health service organisations use an open disclosure program consistent with the Australian Open Disclosure Framework (the framework) and that it acts to improve the effectiveness of open disclosure processes.

At the time of Arthur’s death, CHHHS did not have a procedure that advised staff on how the open disclosure process was to be conducted or implemented.

Health Ombudsman’s finding:

It is evident CHHHS did not effectively communicate with the complainant regarding how they planned to manage open disclosure in the weeks following Arthur’s death or advise realistic timeframes for the commencement and completion of the RCA report. The complainant’s confusion and dissatisfaction with the process could have been minimised or prevented had the CHHHS followed the recommended processes outlined in the framework.

Since the incident the CHHHS has introduced an open disclosure procedure which includes a detailed flowchart documenting the stages and decision points of the process; it also includes a number of templates for implementing different components of the process, including a letter and checklist. However, the procedure does not include reference to, or minimum requirements for, a number of essential requirements.

I recommend the CHHHS review the procedure to ensure it is aligned with the framework and clearly documents the expectations and requirements of clinicians when conducting open disclosure following a serious or unexpected adverse outcome.

Issue 5—Corporate and clinical governance

Clinical governance is a component of corporate governance and ensures good clinical outcomes through accountability for the delivery of safe, effective, high quality and continuously improving health services.

Good governance is fundamental to good practice and is characterised by a well-managed organisation. The critical role of governance systems and management processes in setting, monitoring and improving organisational performance is recognised through the National Safety and Quality Health Service Standards, standard 1 – Governance for Safety and Quality in Health Service Organisations. The aim of this standard is to ‘create integrated governance systems that maintain and improve the reliability and quality of patient care as well as improving patient outcomes’.

Health Ombudsman’s finding:

The CHHHS’s response to the OHO’s requests on key discussion points—combined with information provided by clinicians during the site visit—demonstrated CHHHS’s commitment to strengthening governance systems to deliver quality services and meet community needs. It is evident the safety and quality governance changes made by CHHHS have strengthened patient safety and quality improvement systems, in particular clinical incident management systems and the timely implementation of meaningful recommendations.

It is evident to me CHHHS has introduced a number of key changes to ensure the effective integration of corporate and clinical governance systems that meet the essential elements of good governance. I encourage the CHHHS board and leadership teams to continue to review and evaluate governance systems to ensure the HHS continues to achieve the best possible health outcomes for Queenslanders seeking care within its region.

I am satisfied initiatives introduced by CHHHS to improve the quality and timely implementation of recommendations have resulted in a more effective patient safety and quality improvement system. However, due to the seriousness of the issues identified regarding the management of recommendations, I recommend a further review to be conducted in 12 months’ time to ensure recommendations arising from mental health SAC1 incidents and other relevant reviews and/or investigations are appropriate and implemented in a timely manner.

Recommendations

1. I recommend the CHHHS undertake a review of the open disclosure procedure to ensure all key elements of the Australian Open Disclosure Framework are referenced in the procedure and that training provided to staff on open disclosure is consistent with this procedure.
2. I recommend the Office of the Health Ombudsman conduct a review in 12 months’ time to ensure recommendations arising from mental health SAC1 incidents and other relevant reviews and/or investigations are appropriate and implemented in a timely manner.

Conclusion

As Health Ombudsman and on behalf of this office, I would like to thank the CHHHS for their cooperation throughout the duration of this investigation; this has involved the collation and provision of extensive documentation, assistance in arranging the three day site visit program, and the willingness of staff to meet with my staff to discuss the HHS’s governance arrangements and changes arising from the recommendations.

I would especially like to thank Arthur’s family for their patience with the office during this lengthy investigation. Additionally, I acknowledge the complainant’s ongoing advocacy for his son and other patients of the Cairns Hospital MHU.

The CHHHS had the opportunity to review this report prior to publication. CHHHS acknowledged the report and has accepted the recommendations in full.

For media: read the media statement