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The Neville Report (June 2006): an Investigation Into the Adequacy of the Health Complaint Mechanisms In

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The Neville Report (June 2006): an Investigation Into the Adequacy of the Health Complaint Mechanisms In Report of the Queensland Ombudsman The Neville Report An investigation into the adequacy of the health complaint mechanisms in Queensland, and other systemic issues identified as a result of the death of Elise Neville, aged 10 years. June 2006 © Queensland Ombudsman, 2006 Apart from any fair dealing for purposes related to the functions of the Ombudsman or the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part of this document may be reproduced by any process without permission. Inquiries should be made to the publishers, Queensland Ombudsman. Queensland Ombudsman Level 25, 288 Edward Street Brisbane Qld 4000 GPO Box 3314 Brisbane Qld 4001 Tel: (07) 3005 7000 Fax: (07) 3005 7067 Email: [email protected] Web: www.ombudsman.qld.gov.au Contents ABBREVIATIONS AND DICTIONARY .................................................................................................. III EXECUTIVE SUMMARY ............................................................................................................................ V 1 BACKGROUND ............................................................................................................................ 1 1.1 INTRODUCTION ................................................................................................................................. 1 1.2 THE ROLE OF THE QUEENSLAND OMBUDSMAN ................................................................................ 1 1.3 PROCEDURE FOR GATHERING EVIDENCE ........................................................................................... 2 1.4 STANDARD OF PROOF AND SUFFICIENCY OF EVIDENCE ..................................................................... 3 1.5 PROCEDURAL FAIRNESS AND NATURAL JUSTICE ............................................................................... 3 1.6 DIRECTORS-GENERAL OF QUEENSLAND HEALTH ............................................................................ 4 1.7 THE INCIDENT................................................................................................................................... 5 1.8 SUMMARY OF THE COMPLAINTS MADE TO THE AGENCIES ................................................................. 7 1.9 PARTICULARS OF COMPLAINT TO OMBUDSMAN ............................................................................... 8 1.10 THE INVESTIGATION ......................................................................................................................... 9 1.11 THE HEALTH PRACTITIONERS TRIBUNAL ....................................................................................... 10 1.12 SUBMISSION TO THE BUNDABERG HOSPITAL COMMISSION OF INQUIRY ......................................... 10 1.13 COMPLAINTS MANAGEMENT PROJECT ........................................................................................... 11 1.14 THE CORONER ................................................................................................................................ 12 1.15 RECENT LEGISLATIVE DEVELOPMENT ............................................................................................. 12 2 THE INVESTIGATION ............................................................................................................. 13 2.1 INITIATION ..................................................................................................................................... 13 2.2 PROCESS ......................................................................................................................................... 13 2.3 OTHER INDEPENDENT INVESTIGATIONS .......................................................................................... 15 3 QUEENSLAND HEALTH ......................................................................................................... 19 3.1 ACTIONS TAKEN BY QH IN RESPONSE TO ISSUES RELATING TO THE DEATH OF ELISE NEVILLE ...... 19 3.2 QH‟S RESPONSE TO THE COMPLAINANTS‟ ALLEGATIONS ................................................................ 22 3.3 CLINICAL AND SYSTEMS PROBLEMS RAISED BY THE NEVILLES‟ COMPLAINT .................................. 25 3.4 OBSERVATIONS ON ISSUES RELATING TO THE NEVILLES‟ SPECIFIC COMPLAINTS ........................... 52 3.5 RECENT ALLEGATION ABOUT COPY OF EXTERNAL INVESTIGATOR‟S REPORT PROVIDED TO DR NEVILLE ......................................................................................................................................... 71 3.6 RESPONSE BY QUEENSLAND HEALTH ............................................................................................. 72 3.7 OBSERVATIONS .............................................................................................................................. 74 3.8 INDEPENDENCE OF EXTERNAL INVESTIGATOR ............................................................................... 76 4 QUEENSLAND HEALTH’S COMPLAINTS MANAGEMENT FRAMEWORK .............. 80 4.1 COMPLAINTS MANAGEMENT .......................................................................................................... 80 5 HEALTH RIGHTS COMMISSION .......................................................................................... 89 5.1 ACTIONS TAKEN BY THE HRC ........................................................................................................ 89 5.2 HRC‟S RESPONSE TO COMPLAINANTS‟ ALLEGATIONS .................................................................... 94 5.3 OBSERVATIONS .............................................................................................................................. 96 6 MEDICAL BOARD OF QUEENSLAND ................................................................................. 98 6.1 ACTIONS TAKEN BY THE MBQ ....................................................................................................... 98 6.2 MBQ‟S RESPONSE TO THE NEVILLES‟ ALLEGATIONS ................................................................... 100 6.3 OBSERVATIONS ............................................................................................................................ 103 7 QUEENSLAND NURSING COUNCIL .................................................................................. 109 7.1 ACTIONS TAKEN BY THE QNC ...................................................................................................... 109 7.2 QNC‟S RESPONSE TO THE NEVILLES‟ ALLEGATIONS .................................................................... 111 7.3 OBSERVATIONS ............................................................................................................................ 114 8 THE HEALTH COMPLAINTS SYSTEM IN QUEENSLAND ........................................... 127 8.1 ISSUES RAISED BY THE NEVILLES‟ COMPLAINT CONCERNING THE ADEQUACY OF THE CURRENT HEALTH COMPLAINTS SYSTEM ...................................................................................................... 127 8.2 SUBMISSION TO THE BUNDABERG HOSPITAL COMMISSION OF INQUIRY ....................................... 129 i 9 BUNK BEDS .............................................................................................................................. 137 9.1 OFT‟S RESPONSE TO THE NEVILLES‟ COMPLAINT......................................................................... 137 9.2 INTRODUCTION OF AUSTRALIAN SAFETY STANDARD 4220:1994 ................................................. 139 9.3 INJURY STATISTICS : CASE FOR REFORM ....................................................................................... 140 9.4 INTRODUCTION OF A MANDATORY STANDARD FOR BUNK BEDS .................................................... 142 9.5 OFT‟S ACTIONS FOLLOWING THE INTRODUCTION OF MANDATORY SAFETY REQUIREMENTS ........ 143 9.6 BUNK BEDS IN GOVERNMENT-OWNED ESTABLISHMENTS .............................................................. 145 9.7 OFT‟S RESPONSE TO THE COMPLAINANTS‟ ALLEGATIONS ............................................................ 145 10 MEDICAL RETRIEVAL SYSTEM IN QUEENSLAND ...................................................... 148 10.1 BACKGROUND .............................................................................................................................. 148 10.2 ELISE NEVILLE‟S RETRIEVAL........................................................................................................ 148 10.3 HRC INVESTIGATION ................................................................................................................... 149 10.4 RECENT REVIEWS OF THE AEROMEDICAL RETRIEVAL SYSTEM IN QUEENSLAND ........................... 150 10.5 QH‟S RESPONSE TO HRC‟S RECOMMENDATIONS ......................................................................... 151 Appendix 1: Ombudsman’s submission to the BHCI .............................................................. 156 Appendix 2: Findings and recommendations by the External Investigator ........................... 201 Appendix 3: Extract from my response to Peter Forster of the Queensland Health Systems Review ................................................................................................................................. 203 Appendix 4: Director of Proceedings ......................................................................................... 206 Appendix 5: Northern Territory, New Zealand and Tasmanian Code of Health Rights...... 207 Appendix 6: The Independent Patient Advocacy System in the UK and New Zealand ........ 226 Appendix
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