Monday, 21 March 2016

Staff Disciplined after Hepatitis C Outbreak

Death of 12 patients in Hep C outbreak: Minister clarifies that pain and regret are greatest punishment senior staff have to bear

The Health Minister in his response to Non-Constituency Member of Parliament Leon Perera, refused to disclose the names and the specific punishments meted out to them with regards to the Hepatitis C outbreak in Singapore General Hospital (SGH) which claimed eight lives.

The Minister, Mr Gan Kim Yong arguing that such disclosures would not contribute to better care of patients said that focusing on naming the individuals will develop a “blame culture in our healthcare institutions.”

Mr Gan emphasised that his Ministry wants “to encourage a learning culture to make our hospitals as safe as possible for our patients,” as “this culture of continual learning and improvement is important for enhancing patient safety and the quality of care.”

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Hep C outbreak in SGH: Leon Perera counters Gan Kim Yong – It’s about public accountability not assigning blame

Today, right after the Minister for Health answered the two questions filed on the Hepatitis C cluster at SGH, Parliamentary Question time ended and there was no time for Supplementary Questions.

I had asked for details of the penalties and warnings given:
  • to whom they were awarded and
  • for what action or inaction.
The Minister declined to disclose this information and alluded to not wanting to create a culture of blame.


WP LEON PERERA: HEALTH MINISTER REFUSE TO DISCLOSE GUILTY PARTIES OF THE HEP C OUTBREAK

I had hoped to ask, as supplementary questions:

  • if the public does not know what actions (or inaction) met with what warning or penalty, how do these penalties act as a deterrent to others?
  • if the lapses were not that serious, as suggested by the fact that only financial penalties and warnings were given, what harm would be done to the individuals for that information to be disclosed? It would, in fact, help clear their name of suspicion of more serious misconduct. After all, their current and likely future employers would probably know of these penalties, so they would suffer no further career disadvantage from such disclosure.
  • without disclosure, other senior staff at MOH and SGH may have to live with public suspicion that they were involved in the incident and committed lapses when they did not, which is not fair to them.
This is not about the allocation of blame but ensuring a culture of public accountability and bolstering public confidence in Singapore’s healthcare system.

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Hepatitis C outbreak: Don’t want a ‘blame culture’, says Health Minister

SINGAPORE needs to have a “learning culture” instead of a “blame culture”, Health Minister Gan Kim Yong said in Parliament today.

This, in response to Non-Constituency MP Leon Perera’s request to reveal the names of the staff involved in the Hepatitis C outbreak in the Singapore General Hospital’s (SGH) renal ward between last April and June. He said that revealing the names would not benefit patients or caregivers.

Without giving names or specific designations, Mr Gan said: “Naming the staff does not contribute to better care of patients. We have to bear in mind the long-term impact on healthcare patients and caregivers.” Singapore needs to have a “learning culture” in order to “improve the system”, he added.


Health Minister: No Point Disclosing Names and Punishment of Staff Blamed for Hepatitis C Outbreak
“In deciding what to disclose, we have to bear in mind the longer-term impact on our healthcare system and healthcare workers, and strike a careful balance.”
Health Minister Gan Kim Yong said in parliament today that the names of those disciplined for the Hepatitis C outbreak last year will not be disclosed because such disclosure “will not contribute to better care of patients.”

He said that it’s more important to focus on a culture of learning rather than blame.

In total, four MOH officers holding Director-level or equivalent roles and 12 SGH leaders including senior management were punished.



Six silly scenarios you get from MOH’s “learning culture”

MISTAKES have been made, people have died, but clearly the best way to handle a Hepatitis C outbreak-gone-wrong is to keep mum about who did what (assuming the Health Ministry actually knows who did what) and drop some utterly inane reasons for why you’re not saying what you’re not saying. Oh, don’t worry if it looks like you’re trying to cover something up or trying to protect someone important.

What every Singaporean should learn from the SGH Hepatitis C tragedy is:
  • Not naming is learning
  • Think of the “Longer term impact”
  • “Blame culture” supercedes accountability
  • “Pain and regret” are worse than publicity
  • What to do when you can’t pinpoint a culprit
  • “Better care for patients” trumps… everything

ST lays the smackdown on MOH over how it handled punishing staff involved in Hep C outbreak
ST had to basically publish the press releases by MOH and SGH, with the MOH spokesperson stating the obvious that those with high level of responsibilities will receive heavier penalties.

Enter The Straits Times‘ Senior Health Correspondent, Salma Khalik, who endured MOH’s non-reply for a day before writing this hard-hitting commentary (“Name those responsible for Hep C infections at SGH“) today.

Here are some of the key points she made:
  • She is disappointed… Very disappointed.
  • Because no one knows who is at fault, how they were at fault, and what disciplinary action has been taken against each of them.
  • Khalik pointed out why MOH’s reason of “staff confidentiality” is flawed.

Hepatitis C Outbreak – Senior hospital and Ministry staff who failed to intervene early warned and fined

In keeping with Singapore’s culture which does not encourage top leaders to resign whenever things go wrong on their watch, 12 staff in leadership positions in Singapore General Hospital (SGH), and four director-level Ministry of Health (MOH) officers have been dealt with in the case of Hepatitis C outbreak, by the hospital and Ministry respectively.

SGH said that following the release of the Independent Review Committee’s (IRC) investigation of the outbreak, it appointed a Human Resource Panel to examine the roles, responsibilities and actions of key SGH staff to assess if disciplinary actions need to be taken.

While MOH said that it took its senior staff to task for “their failure to intervene early and to ensure the infectious disease notification and reporting system was effective and rigorous.”


Hepatitis C Outbreak at Singapore General Hospital – Update on Follow-up Actions by MOH

Following the release of the report of the Independent Review Committee (IRC) tasked to look into the Hepatitis C outbreak at the Singapore General Hospital (SGH)’s renal ward, the Ministry of Health (MOH) in December 2015 set up a Taskforce to Strengthen Outbreak Detection and Response, led by Minister of State for Health, Mr Chee Hong Tat.

In its report submitted to MOH on 5 December 2015, the IRC found that the outbreak was due to multiple overlapping factors, including gaps in infection control procedures and protocols at SGH’s renal ward. On the overall system response to the outbreak, the IRC noted that while the current national surveillance system worked well for detecting community outbreaks of known infectious diseases, the Hepatitis C virus (HCV) outbreak had highlighted a gap in the current system. As an unusual healthcare-associated infection (HAI) with unique characteristics, HCV was not easily picked up through regular surveillance. Within MOH, there was also no designated division with the responsibility and capabilities to deal with an unusual HAI like HCV. These resulted in delayed recognition and escalation of the HCV outbreak.

The Taskforce was to address the IRC’s recommendations on improving the national healthcare system’s ability to detect and respond to infectious disease outbreaks in hospitals and the community. It has held several meetings and engagement sessions to discuss its preliminary proposals on strengthening outbreak detection and response over the past few months. These include the setting up of the National Outbreak Response Team and a review of the list of notifiable diseases under the Infectious Diseases Act and the modes of notification, timelines and escalation process. The Taskforce is on track to complete its review by June 2016.


Update by SGH Following Report of the Independent Review Committee’s Investigation into the Hepatitis C Cluster

Following the Report of the Independent Review Committee’s (IRC’s) investigation, our priority has been to continue to care for the affected patients and their families, and to follow up intensively on the gaps highlighted by the IRC.

Ensuring the well-being of affected patients and their families - The care team at SGH has a long and close relationship with our patients and feels deep regret for what happened.

Since the cases were detected, our doctors, nurses and medical social workers have been reaching out to our affected patients and their families to address their concerns and queries, and provide psychological and emotional support.

SGH has given each patient appropriate medical treatment from the time they were diagnosed. The patients remain under close care of the medical team. SGH will continue to ensure that the affected patients receive the necessary treatment, and will pay for the HCV treatment and related costs.


Name those responsible for Hep C infections at Singapore General Hospital

Why do I feel let down by the press releases from the Ministry of Health (MOH) and the Singapore General Hospital (SGH) that should have provided closure to the Hepatitis C outbreak at the hospital?

That outbreak infected 25 patients over several months last year. 8 patients died, and 7 of those deaths were possibly linked to the infection.

The findings of the 2 teams looking into the action of people at MOH and SGH had been long awaited. The public had expected to know whether anyone was at fault, and if some of those infections and deaths could have been prevented.


Senior MOH, SGH staff disciplined for role in hep C outbreak

4 senior Ministry of Health (MOH) officials and a dozen Singapore General Hospital (SGH) staff in leadership positions have been disciplined for not doing enough in last year’s fatal hepatitis C outbreak at the hospital’s renal ward.

The outbreak was made public in Oct 6 last year, almost 6 months after the first case was diagnosed on April 17. In all, 25 patients were affected, of whom eight have died.

The ministry and SGH gave separate updates on the matter on Thursday (Mar 17) but were tight-lipped on the identities of the 16 individuals. MOH said its four staff who were warned, sternly warned and fined were at director-level or equivalent, while SGH said its 12 staff “sternly warned and fined” included senior management.


Staff disciplined after hepatitis C outbreak

An HR panel set up to investigate last year’s hepatitis C outbreak at Singapore General Hospital (SGH) has recommended disciplinary action against 12 senior staff from SGH and four senior officials from the Ministry of Health (MOH).

The outbreak involved 25 patients and was connected with eight deaths. It was said to be caused by gaps in infection control procedures and protocols in SGH’s renal ward.

Both MOH and SGH released separate statements yesterday (17 March).


Hep C outbreak: Mixed and muffled signals – and blood

So I’ve read the Independent Review Committee report on the Hepatitis C (Hep C) outbreak in the Singapore General Hospital (SGH) and I can tell you the one thing that stuck with me was this: blood stains.

The committee found a blood stain on the wall of a “preparation’’ room for Ward 67. This area is supposed to be very, very clean because this is where trolleys for the preparation of intravenous medications are parked. The stain tested positive for the Hep C virus. Blood stains were also found on trolleys, medication carts and an injection tray.

The committee didn’t even think hand hygiene among some staff members was “adequate’’ and saw one staffer use the wrong procedure to inject medication into a patient’s intravenous tube during its rounds.

read more

Name those responsible for Hep C infections at SGH




Doctors hold people's lives in their hands. They must be held accountable for their actions if they fail to uphold this. The same goes for senior ministry officials.


It bears repeating: 25 people were infected and 7 deaths were possibly caused by the outbreak.

Tell us, was it caused by laziness, negligence or ineptitude - or something else altogether. Tell us also that this incident is viewed seriously by spelling out the actions taken.


4 MOH DIRECTORS & 12 SGH STAFF PUNISHED SEVERELY FOR HEP C OUTBREAK

In updates given on Thursday afternoon (17 March 2016), the Ministry of Health and Singapore General Hospital announced disciplinary action taken against 4 MOH and 12 SGH officials for falling short in last year's Hepatitis C outbreak. The outbreak affected 25 renal patients resulting in 8 deaths. MOH and SGH declined to reveal the identities of the personnel punished.

The 12 SGH staff includes senior management figures and their punishments were stern warnings and financial penalties. For frontline nurses caring for patients, SGH disciplinary panel recommended retraining and ensure staff complied with infection control measures.

4 MOH officials that held Director-level positions received warnings, stern warnings and financial penalties for their failure to uphold an effective and timely infectious disease notification


Hepatitis C Outbreak: MOH’s Disciplinary Procedure Raises Doubts Instead of Offering Answers

Those disciplined – 12 staff members holding leadership positions at SGH and 4 senior officials from the MOH

Still, the MOH has once again been founding wanting.

Regarding the outbreak, which saw 25 patients infected and 8 dying from their sicknesses linked to infections, it was lapses in procedure which got the public mad.


Health Minister Gan Kim Yong excuse himself from blame over virus outbreak

In the Hepatitis C virus outbreak incident that took 8 lives and 22 infected last year, 4 senior officials from the Ministry of Health (MOH) and 12 staffs from the Singapore General Hospital (SGH) are singled out for blame and penalized with warnings and fines.

However Health Minister Gan Kim Yong excused himself from taking responsibilities as the press release chastise the 20 staffs. Health Minister Gan Kim Yong did not reveal to the public in May when his ministry confirmed the virus outbreak in May 2015.

The MOH kept quiet about the outbreak for 5 months until Oct 2015 before making a public announcement of the virus outbreak. There was no explanation for the 5 months cover up but it is understood that the delay happened because of the Sep 2015 General Election. The Singapore government was worried that the virus outbreak incident may cost them votes in the election, which the ruling party PAP eventually won with a record 69.8% majority.


Warned and fined, but who are they?

THE Singapore General Hospital (SGH) today (March 17) issued an update following the Independent Review Committee’s investigation into its handling of the Hepatitis C outbreak last year.

Twelve of its staff members holding leadership positions, including senior SGH management roles, have been warned and fined, the hospital said.

In a separate press release, the Ministry of Health (MOH) said that four MOH officers were also disciplined with fines and warnings for “their failure to intervene early”, adding that the officers had failed to ensure that the infectious disease notification and reporting system was “effective and rigorous”. The four officers were directors or held equivalent roles.


Hepatitis C outbreak: Slap on the wrist for SGH and MOH staff

Many have commented online that had last year’s Hepatitis C outbreak happened during the late Lee Kuan Yew’s watch, many heads at the respective departments or ministries would have been out of a job, especially when precious lives were lost.

Luckily for the staff at Singapore General Hospital (SGH) and Ministry of Health (MOH) who were directly or indirectly responsible for the Hepatitis C outbreak, it didn’t happened under the late Mr Lee’s watch.

Disciplinary action taken - In a press release today (17th Mar), SGH said that 12 of its staff in leadership positions were given “stern warnings and financial penalties” for gaps in their roles in managing the outbreak or in infection control.



Senior hospital and Ministry staff who failed to intervene early warned and fined

In keeping with Singapore’s culture which does not encourage top leaders to resign whenever things go wrong on their watch, 12 staff in leadership positions in Singapore General Hospital (SGH), and four director-level Ministry of Health (MOH) officers have been dealt with in the case of Hepatitis C outbreak, by the hospital and Ministry respectively.

SGH said that following the release of the Independent Review Committee’s (IRC) investigation of the outbreak, it appointed a Human Resource Panel to examine the roles, responsibilities and actions of key SGH staff to assess if disciplinary actions need to be taken.

While MOH said that it took its senior staff to task for “their failure to intervene early and to ensure the infectious disease notification and reporting system was effective and rigorous.”


INDEPENDENT REVIEW COMMITTEE RELEASES REPORT ON HEPATITIS C CLUSTER IN SGH RENAL WARD

The Independent Review Committee (IRC) chaired by Professor Leo Yee Sin has concluded its review of the Hepatitis C cluster in the Singapore General Hospital (SGH)’s Renal Ward and submitted its report to the Ministry of Health (MOH) on 5 December 2015. (The composition of the IRC is at Annex A, while information on the Hepatitis C virus (HCV) is at Annex B.) MOH has accepted the Report.

Findings on Extent and Causes of the Hepatitis C Virus (HCV) outbreak - On the extent of the outbreak, the IRC concluded that the 25 cases in the cluster were localised to the two affected wards in SGH, Ward 64A and Ward 67.

In investigating the cause of the outbreak, the IRC tapped on resource persons and experts, received reports and information from SGH and MOH, conducted site visits and interviewed staff involved. It narrowed its study to four possible hypotheses – (i) drug diversion; (ii) intentional harm; (iii) contaminated medical products; and (iv) breaches in infection control. The first three hypotheses were ruled out.

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Difference between review committee and committee of inquiry

On Sunday, the Workers’ Party (WP) called for the current review committee appointed to look into the hepatitis C saga at the Singapore General Hospital (SGH) to be reconstituted as a Committee of Inquiry (COI) under the Inquiries Act.

In response to this, the Ministry of Health (MOH) said the findings and recommendations of the current review committee will be made public. A police report has also been filed and the police are conducting investigations. The ministry also said,
“The WP statement is careful not to make any suggestion that SGH or MOH officers acted with improper motives. Yet it has asked for a COI ahead of the Committee’s report and the conclusion of Police investigations. If the WP believes that there are questions that the Committee cannot answer, or that any officer acted with improper motives, it should state so directly. The Government will convene a COI provided the WP is prepared to lead evidence before the COI, to substantiate whatever allegations it might have.”
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ST lays the smackdown on MOH over how it handled punishing staff involved in Hep C outbreak

Last Thursday (Mar 17), the Ministry of Health (MOH) published a 800-word, 11 para-press release to update the public on its follow-up actions following the Hepatitis C Outbreak at the Singapore General Hospital (SGH).
 
Some background: 25 people were infected and seven deaths were possibly caused by the Hep C outbreak. The Independent Review Committee was formed and released its report on Dec 8, placing the lapses mainly on the SGH and its poor infection prevention and control practices. MOH was not spared, for gaps were also found in MOH’s infectious diseases reporting system.
 
This led to the formation of  a National Outbreak Response Team led by Minister of State for Health Chee Hong Tat, a “national-level ‘SWAT team’ in his words, to deal with disease outbreaks.
 
related: Review committee places fault of Hep C outbreak on poor practices at SGH


New task force to boost infection control in hospitals

Health Minister Gan Kim Yong has set up a task force to strengthen infection control in all hospitals following the release of the report on the hepatitis C outbreak at Singapore General Hospital (SGH) in which 25 patients were infected and eight have died.

The task force is headed by the Ministry of Health's (MOH) new Minister of State Chee Hong Tat and will see how the surveillance and detection of infectious diseases, both in hospitals and in the community, can be enhanced.

"This is a very painful incident for all of us," Mr Gan told the media yesterday. "We must be determined to learn from this incident so that we can improve and be better."


Hep C outbreak at SGH: Health Minister apologises

The Health Minister made a rare apology yesterday.

Mr Gan Kim Yong spoke after an independent review committee (IRC) into the hepatitis C infection at Singapore General Hospital pointed to lapses at SGH and gaps in the Ministry of Health's (MOH) infectious diseases reporting system.

"I would also like to take this opportunity to apologise to our patients and their family members, and I'm sorry for the lapses in the system," he told reporters after the IRC's announcement yesterday.


Infection-prevention lapses were key factor in SGH Hep C outbreak

LAPSES in infection prevention and control practices played a key role in causing the hepatitis C (hep C) outbreak in the renal ward of the Singapore General Hospital (SGH) between April and June.
 
Of the 25 patients who contracted the illness, eight died. The independent committee tasked to investigate the case said the hep C virus likely caused the deaths of seven of them.
 
These were some of the findings in the report submitted by the committee to the Ministry of Health (MOH) last Saturday.
 
 
Full Coverage:
4 MOH and 12 SGH senior employees disciplined for Hep C
Senior MOH, SGH staff disciplined for role in hep C outbreak
Case Closed! 16 MOH AND SGH staffs given fines and
4 MOH, 12 SGH staff disciplined for role in hepatitis C
4 MOH and 12 SGH staff disciplined for role in hepatitis C
SGH, MOH senior staff penalised over 2015 SGH Hep C
SGH hepatitis C outbreak: 16 staff disciplined, news
SGH, MOH staff disciplined over Hep C outbreak
SGH hepatitis C outbreak: 16 staff disciplined, news
SGH, MOH staff disciplined over Hep C outbreak
TODAYonline | Comprehensive Singapore and international
Hepatitis C saga: 16 penalised, systems strengthened
Hepatitis - news.google.com.ng
Name those responsible for Hep C infections at SGH

Review Committee finds fault with SGH’s practices on Hepatitis C outbreak
Photo – The Straits Times, Tan Weizhen

The report by the Independent Review Committee (IRC) has found that sloppy practices, including poor infection control, led to the Hepatitis C outbreak in Singapore General Hospital’s (SGH) renal wards 64A and 67 where 25 patients were infected between the period of April and June 2015.

The report by the review committee was submitted to the Ministry of Health (MOH) on 5 December and has been accepted by the ministry.

The independent review committee headed by Professor Leo Yee Sin, the director of the Institute of Infectious Diseases and Epidemiology, was announced by MOH on 6 October to review the report by SGH submitted to the ministry on 24 September. The review committee was convened on 28 September by the Minister of Health, Gan Kim Yong.


What is missing in SGH report
Associated Press/Joseph Nair - The windows of wards are seen with the sign of Singapore General Hospital on Tuesday, Oct. 6, 2015 in Singapore. The top public hospital in Singapore said Tuesday that four of its patients died after a new renal ward was hit by an outbreak of hepatitis C, likely from intravenous treatment. (AP Photo/Joseph Nair)

It must be the briefest statement to end a brewing crisis. And it was said with a firm air of finality.

“There is no evidence to suggest that the escalation from the director of medical services to the minister was deliberately delayed,” Leo Yee Sin, chairman of the committee that investigated the Hepatitis C scare at SGH, said last week.

Their report was damning, exposing lapses in protocols at Singapore’s oldest hospital. This pride of Singapore’s health care industry was tardy in recognising the outbreak, its own investigations were messy and there were delays in reporting the matter to the Ministry of Health.


Review committee places fault of Hep C outbreak on poor practices at SGH

It also found no evidence of deliberate delays by SGH or MOH staff in escalating the outbreak or in informing the Minister for Health.

It’s in — the independent review committee that looked into the Hepatitis C virus (HCV) outbreak at Singapore General Hospital (SGH) has released its report on its findings today (December 8).

Three days prior, their report was submitted — and later accepted, by the Ministry of Health (MOH), and if you’d like to read the entire thing, it’s available here. It’s 80 pages long, though, so we thought we’d take you through some key points from a shorter version of it:



Ministry of Health’s Review Committee on virus outbreak: SGH staffs at fault

The Independent Review Committee set up by the Ministry of Health (MOH) blamed staffs at the Singapore General Hospital (SGH) for the Hepatitis C virus outbreak occurred between April and June.

According to the 79-page report, SGH staffs committed multiple breaches of infection control:
  • Not following standard procedures in administering blood-taking and giving medication
  • Inefficient workflow designs
  • Contaminated medical equipment and environment due to inadequate cleaning and disinfection practices
7 patients living in affected wards died due to the infection. Police investigations have also revealed no foul play. However it is not mentioned if the SGH staffs guilty of the infection control breaches will be taken to task for criminal negligence leading to deaths.



Hepatitis C Outbreak: SGH’s Sloppiness Killed Patients, Says Independent Committee
25 people were infected with Hepatitis C and 8 of those in the affected ward died – with 7 deaths linked to the infection. All this, due to sloppy handling of equipment by staff at Singapore General Hospital

That was the finding of the Independent Review Committee, tasked with investigating the outbreak which was covered up for months before word spread to the Ministry of Health, and Singapore’s Health Minister.

18 spot checks found that staff were lax with the hygiene, and the handling of contaminated equipment.

The committee also found that there were gaps in infection prevention and control practices, failure by SGH to recognise the outbreak, and delays in notifying the higher-ups in the hospital as well as the MOH.


SDP calls for Minister of Health to take responsibility for Hep C incident

Singapore Democratic Party (SDP) calls for Minister for Health Mr Gan Kim Yong to take responsibility for the Hepatitis C episode which took place during April to June this year that had 25 patients infected and claimed seven lives.

The press release which was signed off by Dr Chee Soon Juan, SDP’s Secretary-General, pointed out that the incident is the largest recorded hospital outbreak of hepatitis C in Asia and one of the largest in the world with tragic consequences for many families, yet the outbreak was allowed to “smoulder for months before the public and, in particular, those at risk were alerted”.

SDP goes on to state that the report released by the Internal Review Committee (IRC) appointed by the Ministry of Health (MOH) over the Hepatitis C infections saga “puts the blame squarely on the Singapore General Hospital (SGH) staff and seemed eager to absolve the MOH of its responsibilities over the matter”.

read more


WP calls for stronger response and escalation framework after Hep C outbreak

 
A stronger response and escalation framework for Healthcare-Associated Infections (HAIs) is required after the outbreak of Hepatitis C at the Singapore General Hospital (SGH), said the Workers’ Party in a press release on Wednesday.
 
The Independent Review Committee convened to look into the outbreak – which contributed to the deaths of seven patients – released its report yesterday, citing a combination of overlapping factors, such as poor infection control and sloppy practices at SGH, as leading to the incident. The Ministry of Health (MOH) has announced that it will put together a taskforce to look at the recommendations of the committee and determine an action plan.
 
“We urge this taskforce to solicit feedback widely from the medical profession and the broader public,” read the WP’s statement, which was signed off by Non-Constituency Member of Parliament Leon Perera, who is part of the WP Executive Council’s media team. “We also recommend that this taskforce be co-led by a respected, retired healthcare professional to ensure that recommendations are formed from a perspective of sufficient independence from the existing organization structure. This taskforce bears a heavy responsibility as MOH is the last line of defence against failures in any healthcare institution.”
 
 
What Singapore’s lead opposition parties said in response to the Hep C review report
WP decided to call off its crusade for a COI, while SDP somehow managed to link it to ministerial salaries

On Tuesday, we saw the independent review committee tasked with investigating the closely-watched Hepatitis C outbreak at the Singapore General Hospital’s renal unit release their report for public scrutiny (and in case you missed it, you can read our summary of it here).

The Workers’ Party:
  • Decided to abandon its pursuit of launching a Committee of Inquiry into the matter (whew).
  • Suggested things it hopes the newly-formed taskforce (to be headed by this MP-elect, by the way:) will look into
Singapore Democratic Party:
  • Noted that the report seemed to absolve the Ministry of Health of blame over what had happened.
  • Asked when the serious information circulating various divisions was communicated to the highest levels of authority in the ministry, calling for the release of emails and communication among those involved.
  • Declared that the Health Minister should take responsibility for the communication taking place within his ministry, and also should take responsibility for the seven Hep C-linked deaths that occurred as a result of the outbreak.
  • Said that if exceptionalism is a justification for high salaries, ministers should not be excused for lapses like this.
read more

IRC report shows escalation and notification process was flawed and needs overhaul

The report identifies gaps in the infection control procedures for Healthcare-Associated Infections (HAIs) at SGH, as well as in the national system for notification, escalation and response. For example:
  • blood specks infected with Hepatitis C Virus (HCV) found on the wall of Ward 67
  • the delays in the SGH renal unit notifying SGH infection control
  • the MOH-CDD’s failure to classify the initial notifications as acute HCV
  • the failure to perform certain elements of investigation before 3 September, which were only undertaken at the request of the Director of Medical Services (DMS) on 3-17 September
  • SGH senior management and some clinicians assuming that SGH was liaising with MOH-CQPT (Clinical Quality, Performance & Technology Division) and that MOH-CQPT would inform the DMS if necessary
This incident contributed to the loss of seven lives. We should take an extremely serious view of such failings and gaps. We welcome the Minister’s assurance that changes will be made to reduce the risk of this incident recurring, and that the issue of accountability of personnel will be addressed by Human Resource (HR) panels at SGH, SingHealth and MOH. We look forward to reviewing the decisions from these panels when these are made public.

The Independent Review Committee (IRC) has made several recommendations for addressing the gaps it identified, such as creating a team within MOH to deal with outbreaks, improving the national notification and surveillance system for acute HCV and strengthening the escalation process for unusual HAIs. MOH has also announced the formation of a Taskforce to review these recommendations and determine an action plan.


MINISTER MUST TAKE RESPONSIBILITY FOR COMMUNICATIONS BREAKDOWN IN MOH

The report released today by the Review Committee appointed by the Ministry of Health (MOH) over the Hepatitis C infections saga puts the blame squarely on the Singapore General Hospital (SGH) staff and seemed eager to absolve the MOH of its responsibilities over the matter.

For example, it says that while “within SGH, communication with senior management took place early...there was a delay in escalation from...SGH to MOH”.

But this is contradicted by the report itself as the Committee also states that “from late April onwards” – which was when the infections were first discovered – the MOH was informed through three of its divisions serially: beginning with the Hospital Services Division (HSD)'s National Organ Transplant Unit (NOTU), and also the Communicable Diseases Division (CDD) and the Clinical Quality, Performance and Technology Division (CQPT).


Off with (whose) head?
Just whose head should roll? It’s not a surprise that an opposition party would ask for a governing member to fall on his sword – or demand that he be guillotined. It also will be no surprise if the G ignored it

SGH’s parent company, SingHealth, is convening a disciplinary panel and the Health ministry is doing the same. These are normal HR practices and likely to be guarded as internal affairs not meant for public consumption. So a range of penalties will probably kick in if staff members are found wanting during the Hepatitis C outbreak. Warning letter? Suspension? Demotion? Sacking?

The IRC report named no names beyond the people with big titles who had to face the media with public pronouncements. It blamed things that went wrong, rather than the people who allowed things to go wrong or the people who did things wrong. It blamed the unwieldy system of reporting outbreaks, the lack of structures and clear responsibilities with the hospital and the ministry and even the lay-out of the affected ward. But it also said that the outbreak was “unusual” because Hep C patients don’t show symptoms and can only come about when someone takes a good look at lab reports on their blood.

Now, if the sword fell on the medical staff in the ward, you can expect the usual complaint that it is always the “little people’’ who get the chop for not sticking to standard operating procedures when ministering to patients. Maybe some of them deserve this, say, a particularly sloppy medical staff member who doesn’t deserve his or her position as a healthcare professional. Who wants to stay in a dirty hospital ward?



Unhygienic Practices in SGH Persisted Despite Lapses that Caused Hepatitis C Infections

Singapore General Hospital has said it will learn from incident whereby 25 patients were infected with Hepatitis C after staying at one of the hospital’s wards.

But in the wake of the infections, and even as investigators were trying to find the cause of the infections, unhygienic practices continued.

The independent review committee tasked with investigating the outbreak of infections conducted 18 spot checks and found that staff failed to observe appropriate hygiene in handling medical equipment.

Related Posts:
4 Dead After Hepatitis C Outbreak at SGH, Drug Injections Blamed for Infections


Hepatitis C deaths/infection – innocent taxpayers pay the price but SGH, MOH not accountable for screw up?

Singaporeans should not expect any accountability from a own self hold own self accountable PAP government. If PAP had wanted to hold any PAP-appointed CEO/senior civil servants accountable, a COI would have been convened, not another PAP ‘independent’ review committee.

The current situation is similar to another ‘independent’ committee set up to review AIM by MND: it found no misuse of funds by town councils which sold public property at a steep discount to AIM, a PAP-owned company. The outcome of every wayang committee is a foregone conclusion – wait long long for accountability to be addressed.

MOH said that “within MOH, there was no single division with clear responsibility and capability to deal with the issue, resulting in a gap in ownership”. Will even an idiot believe this?


WP calls for Committee of Inquiry on Hep C outbreak
Committee deliberations should be made public; detailed explanation on delay in public notification needed
 
The Workers’ Party (WP) has called for the committee reviewing the Hep C outbreak at the Singapore General Hospital to be reconstituted as a Committee Of Inquiry (COI) under the Inquiries Act, citing a need for the committee’s deliberations to be made public.
 
The party suggested the appointments of retired health-care professionals and clinicians, as well as a person qualified to be a High Court judge, to be part of the COI to “conduct a truly rigorous and, where necessary, critical review”.
 
In the statement from Non-Constituency Member of Parliament-elect Leon Perera, the WP referenced past COIs convened for the 2011 MRT breakdowns and 2013 Little India riot to strengthen public confidence in the public transport and security systems respectively.
 

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