//Supplementary report: Finalisation of the recommendations arising from an investigation into the quality of care provided at Rockhampton Hospital

Supplementary report: Finalisation of the recommendations arising from an investigation into the quality of care provided at Rockhampton Hospital

04 June 2018

This supplementary report details the Office of the Health Ombudsman’s (the office) monitoring of implementation of recommendations arising from an investigation into the quality of care delivered at Rockhampton Hospital in 2014.

In the original investigation report the then Health Ombudsman made four recommendations for improvement to address a number of identified failings in the medical care provided by Central Queensland Hospital and Health Service (CQHHS) at Rockhampton Hospital. Three recommendations were for improvements to the policy, management and safe handling of anticoagulant high risk medication. The fourth recommendation addressed the findings of the Root Cause Analysis (RCA) commissioned by CQHHS.

Monitoring progress

The office actively monitors the implementation status of recommendations to:

  • support and assess the timely and appropriate implementation of recommendations
  • assure the Health Ombudsman and the public that appropriate activities and improvements have been implemented in response to systemic issues identified during an investigation
  • promote the safety and quality of health service delivery through public reporting of shared learnings.

The office prepared a recommendation monitoring plan, in consultation with CQHHS, to monitor the implementation of the recommendations made in the investigation report. CQHHS provided three progress reports on the implementation status of the recommendations.

The office conducted a detailed review and analysis of the information submitted with each progress report; following each assessment the office reported the findings to CQHHS in a recommendation implementation status report. On 27 April 2017, the office advised CQHHS that it sought to finalise monitoring of the recommendations; information was provided on the outcomes of monitoring and the implementation status assigned to each recommendation by the office. The office was satisfied recommendations 1 and 2 had been ‘fully implemented’ and noted the ‘partially implemented’ status of recommendations 3 and 4. The office also provided CQHHS with a summary report of the office’s assessment of the three progress reports.

On 28 June 2017, two senior staff from the investigations division visited Rockhampton Hospital and met with CQHHS staff to discuss improvements arising from the Health Ombudsman’s investigation.


As a result of information provided during the site visit, the office noted recommendation 3 was in the final stages of implementation and recommendation 4 was ‘fully implemented’. The office received confirmation on 29 September 2017 that recommendation 3 had been ‘fully implemented’. The four recommendations are now considered to be ‘fully implemented’.

Corporate and clinical governance

During the site visit, a number of governance elements relating to patient safety and quality improvements systems, and clinical performance and effectiveness were discussed. The CQHHS described a number of improvement initiatives focused on ensuring good clinical outcomes for patients, which are details in the full report. The office acknowledges CQHHS’s commitment to continuously improving health services through good clinical and corporate governance strategies.

Recommendations 1, 2 and 3

Recommendations 1, 2 and 3 were targeted at improving the management and administration of anticoagulant medication, while also aiming to ensure CQHHS had appropriate processes to effectively communicate, monitor and evaluate the policy changes and their impact on patient safety. The office recognises CQHHS has undertaken a significant amount of work to ensure the review of its anticoagulant use policy resulted in a clearer policy that met the needs of patients and staff across the HHS.

In response to the Health Ombudsman’s recommendation to review the policy, CQHHS implemented a number of significant changes to improve the culture around high risk drugs and support safer prescribing, monitoring and administration of therapeutic anticoagulants. CQHHS acknowledged the Health Ombudsman’s investigation had triggered a total ‘rethink’ of the health service’s approach to therapeutic anticoagulants and included changes that are now incorporated into the revised policy.

The office was satisfied the policy changes, combined with a targeted staff awareness and training program and an audit program, demonstrate CQHHS has appropriate systems in place that support the delivery and improvement of quality health services.

Recommendation 4

Recommendation 4 related specifically to the RCA and the implementation of the recommendations arising from the RCA report. Following the review of the three progress reports, the office had originally assessed and assigned recommendation 4 an implementation status of ‘partially implemented’, contrasting with CQHHS’s ‘fully implemented’ status. The site visit provided a valuable opportunity for the office to gain a broader perspective and understanding of the reforms that CQHHS has implemented in response to the recommendations made in the RCA report. It also satisfied and reassured the office that all RCA recommendations had been fully implemented and the issues identified in the RCA had been appropriately addressed.


The Health Ombudsman’s investigation identified areas for improvement in the management and administration of anticoagulant therapy at Rockhampton Hospital, CQHHS. The investigation also considered the implementation status of all recommendations arising from the RCA report commissioned by CQHHS; the office considers full and complete implementation is essential to preventing a similar adverse event from occurring.

Overall, the Health Ombudsman is satisfied all recommendations were fully implemented and confident that the CQHHS has suitable strategies in place to ensure patients continue to receive clinically appropriate services at CQHHS facilities. The progress reports provided by CQHHS demonstrated a commitment to implementing suitable long term policy solutions.

Read the report