Wednesday, 19 March 2025

Health services

Georgie CROZIER (Southern Metropolitan) (15:46): I am pleased to be able to rise and speak to the motion in my name. I move:

That this house:

(1) condemns the lack of action by the Allan Labor government to address the rising number of sentinel events in Victorian hospitals;

(2) notes that:

(a) the 2022–23 sentinel events report found a record number of sentinel events were recorded, including 16 more deaths than the previous year and only 23 per cent of sentinel events were reported within the required three-day reporting window;

(b) in the past five years, the Latrobe Regional Hospital has reported nine sentinel events to Safer Care Victoria (SCV), including:

(i) the deaths of newborn babies and children;

(ii) claims that four sentinel events reported were patients who died due to delayed care and two other patients experienced severe post operative complications and serious lifelong morbidity;

(iii) staff involved in a number of the sentinel events were not interviewed during investigations by SCV;

(iv) one case involving the death of a patient where medical notes show there was chaos on the ward with understaffing and no access to computer systems and pathology;

(v) concerns raised by anaesthetists, surgeons, nurses and midwives on the clinical experience of staff and the lack of education and training provided to doctors;

(c) the Australian Medical Association raised concerns about the lack of consistent oversight and reporting within Victoria’s health system by writing to the Minister for Health in November 2024 and SCV in December 2024; and

(3) calls on the government to immediately undertake a fully independent inquiry into the reporting and investigations of sentinel events.

This is an important motion. Victorians have died in our hospitals and in our healthcare system, and they are deaths that could have been avoided. There has also been concern around comorbidity and issues that have arisen due to mistakes being made in our hospitals.

If I can go to the first point around the lack of action by the government to address this rising number of sentinel events, we have had various sentinel event reports. To go back and just give a little bit of history, Safer Care Victoria was established after there was a cluster of deaths at the Bacchus Marsh Hospital. An independent investigation was undertaken, and out of that investigation and report Safer Care Victoria was formed. The investigation was done by Professor Euan Wallace, an obstetrician, who then became head of the Safer Care Victoria entity within the health department. When the former department secretary Kym Peake left after the debacle of COVID, he took over that position, and just a couple of weeks ago he also left.

Now the department is in chaos. There is no leadership. The senior roles have gone from within the Department of Health, and we have got a huge issue around what is occurring in the Department of Health and how it is being administered and how these bodies within the department are undertaking the work that they are responsible for. That is a bit of a history of how Safer Care Victoria came into being and what it is responsible for – to look at these events – and the reporting mechanism that is supposed to be happening that goes through to Safer Care Victoria, and then investigations occur.

But if I can just get back to the sentinel event reports, there is a bit of a trend in this. I have referred in my motion to the 2022–23 sentinel events report, because that is the last report that the Victorian public has seen. We have not seen the 2023–24 report, and we certainly have not seen any reports relating to this financial year. Normally those reports would be handed down in March, but they have been delayed time and time again, and the last one, that 2022–23 report, was provided 18 months or thereabouts after it was due to be made public. Over that time there has been an increase. In 2020–21 there were 168 sentinel events and in 2021–22 that jumped enormously to 240. Of course that took in the terrible situation of the failures within 000 where over 33 Victorians died. We could not get true transparency of that report about what was actually happening. The government gave us a pathetic report. It was flimsy, a few pages long, half of it was not even filled in, and it had all this waffle at the start. It was a disgrace in terms of this very important issue and what it did not show. The last report that was made public is the one I mentioned, the 2022–23 report, which is from a few years ago now. It showed that there was an increase of five events to 245, but concerningly there were 16 more deaths. There was a huge jump in the deaths and there were also various other issues. There was a spike in medication errors in that report, a 94 per cent increase year over year. That is a very big concern when you think about the number of mistakes, and of course a medication error can lead to very significant co-morbidity issues, but it can also kill you.

Concerningly, there have been reporting delays. Only 23 per cent of sentinel events were reported within the required three-day window. That is what is required for any sentinel event or any adverse issue – a sentinel event of course being a death or an adverse event where somebody is impacted in the hospital. There might have been a medication error, as I have said. There have been tragedies where people have suicided in our hospitals, or the wrong blood was given in a blood transfusion, or delays in care have contributed to a death or a decline in someone’s overall health status. Those could all be regarded as sentinel events, along with many other areas that I have not covered off, but that is just to give you a bit of an idea. When these are increasing as they have been, they need to be reported, and there is a number that have not been, and I want to come back to that with some of the latest data.

The medication errors doubled, and that is a very big concern because that talks about the safety component. Nobody wants to go into hospital and get the wrong medication or have any of these issues arise. Nobody expects to go into hospital and have that happen, and our workers do not want this to occur either. But errors unfortunately do occur, and we need to minimise these as best we can. Part of the way to do that is to identify where these issues are occurring so you can identify the problems and then address them. So it is identifying the problems, looking at the gaps, and then finding out – but if they are not being reported or they are not being investigated properly, then we are never going to know the true extent. That is a concern that has been raised.

In that last report that I mentioned, the event locations: 26 per cent occurred on the wards, 20 per cent in emergency departments, 9 per cent in operating theatres and 9 per cent in intensive care units. The latest reporting shows that in the quarter from October 2024 to December 2024 there still is a very big issue with this reporting and statewide there were still too many health services – Ambulance Victoria was right up there too – that submitted their cases and their investigations late, and there was still some outstanding root cause analysis, which is very concerning. That was Ambulance Victoria, and we have seen those issues today – 300 paramedics not available over the weekend, dozens of ambulances not available on the Saturday night, and that is putting patients at risk

For those delays, if there is a death, it would be in this. If there are investigations going on, that is going to be adding to the total that this data relates to. The other hospitals in this are the Alfred, Northern, Grampians and West Gippsland – very high in their lack of reporting, which is very concerning. We have seen that data. Unfortunately the data found 45 per cent of the investigations were overdue across the state in the services that I have just mentioned. For Monash, Ambulance Victoria and Grampians the rates were between 80 and 100 per cent. That is very, very concerning. The Minister for Health says she too is concerned, but she is actually not addressing the issue that she needs to. For this report, as I said, we need to understand why they are not submitting and not being investigated properly or on time.

I want to just draw attention to part 2(b) of my motion in relation to the Latrobe Regional Hospital. I am not wanting to demonise this hospital in any way or the people involved, but it is a case study of what is happening. And if it is happening here, it will be happening elsewhere. I want to make that point. It is very concerning. There have been nine sentinel events to Safer Care Victoria in the past five years, and these include the deaths of newborns and children. I have spoken to various clinicians who have been involved in these cases, and they have told me what has gone on. I am a former nurse and midwife, and when they explained to me what had gone on I was horrified. What they told me and what they are concerned about should not be happening. That is why they are speaking out, and I want to thank them for having the courage to do so, because if we do not understand what is going on we are never going to fix it.

This government is very good at covering up stuff, and they cover up things time and time again. That is why last March, in fact 12 months ago, I finally got some data around Latrobe Hospital. How did I do that? The government would not give me the data, so I FOI-ed it. It included unreported sentinel events, and it was just really horrifying. There was a failure to even inform Safer Care Victoria. It included patient 1: failure to provide the necessary attention and timely intervention; the delay in providing appropriate treatment ultimately resulted in the loss of their life. For patient 2, medical staff failed to accurately diagnose their condition and administer the required treatment; the on-call surgeon never once attended to the patient in the emergency department. This misdiagnosis and subsequent lack of proper care led to their unfortunate demise – meaning they died. For another patient, failure to diagnose and institute treatment on time resulted in death. For another patient it was untimely death due to negligence.

These issues are very concerning. People are dying because proper treatment and care is not being administered. We need to understand why it is not. That is why I also note that staff involved in a number of these sentinel events were not interviewed by Safer Care Victoria. They think they should have been, because they wanted to give some insight as to what the issues are. But when there are reports around no access to computers or pathology you are going to have a problem. To say, in the instance where there was a tragic death that, and these were the words used:

[QUOTE AWAITING VERIFICATION]

… there was chaos on the ward with understaffing and no access to computer systems and pathology …

you have got a systems issue here. That is what the government can fix. The government cannot fix an accident; you would not expect the government to fix every little issue that happens. But for these – understaffing, no access to computers, no access to pathology – something is not going right and needs to be addressed.

I was just horrified when I was alerted to what went on, what was done and, ultimately, what sadly transpired. That is why those anaesthetists, surgeons, midwives, nurses and others involved have been wanting to fix it. They want to fix this as well. But some of them say that there is a lack of training for some of the staff, and what they are expected to do, they are not trained to do – they do not have the experience or the expertise to do. You should not be putting people in that situation. You should not actually be putting people in this very critical area where there is emergency care required, where diagnoses need to be made and where decisions and management and treatments then occur, if they are not qualified or do not have the expertise to be able to do that. That is a shocking scenario to be occurring in Victoria in 2025. I am very concerned about the expertise that is in our health system and the lack of supervision around the more experienced staff, and we know that those experienced staff are leaving. They have had it. They do not feel supported and they have had enough, and that is where we are having a breakdown. We need to acknowledge this and work through, ‘Well, how do we support those people and how do we support those clinicians that need that experience and expertise?’ That is a very important aspect that is required.

I know the minister last week put in somebody who I used to work with at the women’s hospital, Professor Mark Umstad. He was a bit of a gun in my day, an obstetrician, and some of the members in here might also know him – a very excellent obstetrician and an excellent clinician. He has been put in charge to look at Latrobe regional – only after these issues have been highlighted. It should not have taken till last week for somebody to be overseeing what is going on. But this is not just occurring at Latrobe. As I said, on the other list and at Ambulance Victoria – there are systemic issues within our health system where the systems are failing, and Victorians are sadly dying because they are not getting the proper, appropriate treatment and care. Mistakes are being made.

The AMA was so concerned after these reports as well – and I have been speaking to a lot of stakeholders around this – that they wrote to the minister in November and then to Safer Care in December. It took till January for the AMA, who wrote in November, to even get a response – months later. What on earth are the minister and the government and the department doing if they are not acknowledging these important pieces of correspondence relating to health care in this state, where doctors are highlighting the issues and raising very significant problems in the system? I find that just shows the chaos and dysfunction within government and within the department, and why nothing has been done.

And nothing has been done, even though the government says, ‘Oh, yes. After the child deaths of a few years ago, we put in place Safer Care for Kids.’ They did start that – I acknowledge that – back in 2023 after the horrendous issues that occurred in 2021 and 2022 where:

…we saw an increase in sentinel events related to patient deterioration, particularly in children and young people.

The government is acknowledging there was a deterioration, and they put in Safer Care for Kids. But lo and behold: nothing. They put in a couple of parts of what they recommended to be done, but nothing since August 2024 has been fully implemented, so they have stalled. Again, it shows the dysfunction and the hopelessness of implementing anything around this really important issue.

The Safer Care for Kids project aims to implement three recommendations  –

and they have done some, but if you go to their own website it says:

Phase two of the Safer Care for Kids project is now complete –

but if you go on, there are no updates on progress:

Future progress updates relating to the three recommendations will be provided as they become available.

Well, they have not been available, and this goes back to August of last year. We have had more deaths and more mistakes and more issues that have arisen since those deaths.

I want to just say to all of those people involved, the families of loved ones who have lost their lives in our healthcare system, that we need to do better. We must do better. There must be improvement in this. Certainly on this side we acknowledge the issues, and we need to do better, also for those staff, who are put under so much pressure. There is the wage theft issue I have raised, with the junior doctors – they are exhausted, they make mistakes. That was acknowledged in the commission’s findings.

In the last 30 seconds I have on this motion, I would hope that the house would support it and that the government would immediately undertake a fully independent inquiry into the reporting and investigation of sentinel events, because currently the system is not working. It is broken, and it needs to improve. I hope that members can see the urgency and importance of this motion and give those people who have lost their lives and been impacted by sentinel events the respect to see that that occurs.

Jacinta ERMACORA (Western Victoria) (16:06): I welcome this motion. I think it is always important to be accountable and to have a system in place to be accountable for all things that happen in our health system. At the outset I just want to start off by acknowledging and giving a big thankyou to those that work in our health system. Doctors, specialists, nurses, allied health practitioners, administrators, caterers, cleaners and educators all work together in hospitals and within our health system in a very complex environment, caring for our community, caring for sometimes some of the most vulnerable people in our community and at other times people that are experiencing their most vulnerable health experience. And 99.9 per cent of these team members across all of our hospitals work fantastically together. The systems in place support them to get the best that they can out of the system for their patients.

Every now and again there is not an ideal outcome, and in fact some people experience harm as a result of our health service system. That is what we are talking about today. It is called a ‘sentinel event’, when harm occurs, and that can be harm to someone’s health. On very rare occasions someone may even die as a result. There is a program that accounts for these scenarios. It is called the sentinel event program, and it is a demonstration of our commitment to accountability.

A sentinel event is when something goes wrong with a patient’s care that causes them serious harm or death. Health services must report all adverse patient safety events that result in serious harm or death of a patient while in their care. The Australian Commission on Safety and Quality in Health Care sets out 10 categories of sentinel events, and we have added another one to capture all adverse patient safety events resulting in serious harm or death. We are the only jurisdiction that reports on that category.

When health services review a sentinel event, they follow a process that helps them understand what went wrong and how and why. This is done by a group of experts, including an expert who does not work for the health service and a person representing the patient’s family’s perspective. They write a report, including recommendations to reduce the chance of something similar happening to someone else.

We also report annually on sentinel events, investigations and recommendations. The most recent report showed a 2 per cent increase in sentinel events from the previous year. 2022–23 also saw an improvement in the timelines of reporting of sentinel events. However, there is still more work to be done to improve health reporting and the timeliness of reports. Safer Care Victoria is working with health services to do that. The Minister for Health has also directed Safer Care Victoria to provide urgent advice on how reporting obligations can be further strengthened. Safer Care Victoria also continues to consult with the AMA on measures that can be taken to further improve our systems and processes. When I think of a sentinel event, my thoughts go to patients who have experienced harm or those who have lost someone. It is a very devastating experience, and I want to offer my sympathy and support to anybody who has experienced that.

As you can see from my summary of the sentinel event program, the safety of all patients in our health system is a priority for this government. The best way to maintain the highest standards of safety is to be open and accountable. There was nothing in place when we came to government. It was this government that introduced the accountability we have today. That is why Ms Crozier is able to bring up these figures, because we believe in the transparency of this program. This was clearly not a priority for the previous government, since they did not do it, even though that meant Victorians were less safe, problems were not addressed and those responsible were not be held accountable. That is not the Labor government’s approach. We listen, we review performance, we make hard decisions and we continue to improve. This is clear from our record.

We established Safer Care Victoria in 2017 as our independent safety and quality body. We established the annual sentinel events report, and we made it mandatory for health services to do the following: openly disclose to a patient and their family a written account, formally apologise for the harm suffered and provide a description of a health service’s response to an event and the steps taken to prevent reoccurrence. We also created Victoria’s first chief quality and safety officer. These requirements are on top of the mandatory reporting of all child deaths, which are independently reviewed by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity. The State Coroner also examines all reportable deaths when someone dies unexpectedly during or following a medical procedure.

On the specific matter of Latrobe Regional Health, Safer Care Victoria conducted a review into the service in 2023 following reports of quality and safety issues. Recommendations were developed and are being implemented. Safer Care Victoria are monitoring that implementation. Chief medical officer Professor Andrew Wilson has been appointed to the Latrobe Regional Health safety and quality subcommittee to provide additional expertise, support and oversight. This is our approach. We track performance and listen to concerns. We are transparent about issues and we respond.

Our Safer Care for Kids project demonstrates this commitment. Safer Care for Kids is a family- and carer-led project to improve health outcomes for children and young people in emergency care. It was formed in response to an increased incidence of sentinel events relating to patient deterioration. We proactively brought together more than 100 healthcare leaders, clinicians, patients and families to consider how we might improve the safety and quality of care for children accessing emergency health care in Victoria.

This resulted in three key actions: mandating use of the Victorian Children’s Tool for Observation and Response whenever children or young people have vital signs recorded; establishing an urgent concern helpline and implementing a 24/7 system of virtual paediatric emergency consultation; and strengthening sector awareness of the 24/7 paediatric consultation available via the Victorian virtual emergency department as well as the Paediatric Infant Perinatal Emergency Retrieval service.

In closing, I again acknowledge family members who have experienced harm in the public health system. I also want to acknowledge the hard work of our health professionals. When we seek health care it is reasonable to expect that the care we receive helps, not hinders, our health. I want to reassure health consumers that, thanks to Labor, we record and seek accountability for sentinel events. We now have a system to monitor, account for and prevent these types of events in the future.

Sarah MANSFIELD (Western Victoria) (16:16): I rise to speak in support of this motion before us. There is a patient safety event in at least one in 10 hospital admissions in Australia, with many causing harm to patients. This is not unique to Australia. It happens across similarly resourced health systems around the world, as noted by the World Health Organization. These incidents result in significant economic cost to our community and can cause lasting harm and trauma to patients. I want to acknowledge at the outset all of those who have experienced such harms.

It is important to recognise that even in the very best health systems, like our own, things will go wrong and not all adverse events are preventable. But notably, at least half of adverse events are preventable. While clinicians do not ever set out to cause harm – in fact it is anathema to our very purpose – the reality is that health care, by its nature, is filled with risks. Humans are humans, and mistakes happen, but we should always be working harder to minimise risks and prevent mistakes. Understanding the root cause of clinical incidents is important to identify systemic changes that need to be made to protect patients from similar harms in the future. It is the very least we should do out of respect for those who have been harmed.

There are different ways of classifying clinical incidents, each requiring different levels of reporting and responses. There are near misses, which do not actually cause harm but could have. There are adverse events, which do result in harm – these are things like hospital-acquired infections. Then there are sentinel events. There are different definitions of a sentinel event. This is important, and it is something I will come back to because I think it is an issue that does need to be addressed and it is why I believe that a review is really warranted. According to Safer Care Victoria, in Victoria the term ‘sentinel event’ refers to an unexpected and adverse event that occurs infrequently in a health service entity and results in the death of or serious physical or psychological injury to – there is a certain category for that – a patient as a result of system and process deficiencies at the health service entity.

A sentinel event is the most serious type of clinical incident. It is not related to a patient’s pre-existing condition or disease. These are things like surgery on the wrong part of someone’s body or a death from a medication error. Serious harm is considered to have occurred when, as a result of a serious adverse patient event, the patient has required life-saving surgery or a medical intervention, they have a shortened life expectancy, they have experienced permanent or long-term physical harm or they have experienced permanent or long-term loss of function. These are really terrible events that we do not want occurring in our health systems.

When a sentinel event occurs there are certain reporting obligations on health services and certain investigations that need to take place. The point of reporting these is not to punish health services or their employees. This is really critical. It is to honestly and openly evaluate what could and should have been done differently so that we can learn from what has happened and we can look at how the system can be reformed to prevent harm to patients in the future. There are other ways we can look at for people to prosecute things through the legal system, but sentinel event reporting and investigation is not about punishment. It is not a punitive mechanism.

However, the system in Victoria has been the subject of criticism following perceived failures to adequately identify systemic issues early in the process. There have been significant improvements over the years, which Ms Crozier outlined in the history of the establishment of Safer Care Victoria, and full credit to the government for putting these stronger systems in place. However, attention is on the system once again following a series of tragic events in several regional hospitals involving children.

The death of a child in any circumstance is unthinkably difficult, and when it occurs as a result of failures in the health system it is particularly devastating for families and their loved ones as well as for the health workers who are involved in these situations. My heart absolutely breaks for anyone who has been through this. Given the recent revelations, I do think it is reasonable to again question whether our sentinel events system is adequate.

I want to make it crystal clear that the Greens do not support unwarranted or unjustified criticisms of individual health services. We do not support commentary that singles out any particular health service or is critical of how they operate. We acknowledge the work that has been done by the government and Safer Care Victoria and the work that they continue to do with hospitals to improve their processes. It is worth noting that services that have a higher rate of sentinel event reporting might simply be doing a better job of being transparent and reporting as they should. So having a higher rate of sentinel events does not necessarily mean that a health service is worse; it might actually just be much better at being compliant with its obligations under the current system. That also, though, does not mean there is not a problem, and I will come back to that.

We do not want to create any further disincentives for health services to report sentinel events. If they know that they are going to be dragged through the media or have their reputations trashed for doing what is right, all it will do is incentivise cover-ups and non-reporting. The whole point of a sentinel events system is to detect significant variations between services that might act as a signal that something is not right – either a particular service does need a closer look at because it is having an unusual amount of sentinel events, and that is a real thing, or there is something wrong with the reporting system which means that different hospitals are reporting in different ways. That too is something that really needs further investigation and looking into.

For example, it has become clear from concerns recently raised around the sentinel events system that we need to be looking at the classification of sentinel events and the system that is used here in Victoria. Currently there are two reporting frameworks for sentinel events. There is the Australian Commission on Safety and Quality in Health Care Australian Sentinel Events List, which includes 10 categories of reportable sentinel events. They define a sentinel event as one that is wholly preventable. But in Victoria we also have the category 11, which covers all serious adverse patient events that do not fit into those 10 Australian sentinel events, and they are not all wholly preventable. They are meant to be reported within three days, but sometimes it is uncertain if one has occurred, potentially relating to confusion about which sentinel event definition should be used. These are issues that have been raised by the AMA on several occasions, and we agree that a review of the term ‘sentinel event’ needs to occur in order to determine whether we need to refine that system and provide greater guidance and clarity to health services.

I believe that it is important that all serious adverse events are reported, which is what the current Victorian system is trying to do but perhaps failing to do because of this confusion. Additionally, it is undeniably stressful for those involved in a sentinel event, including in the current investigation process. It is meant to be something that is different to a court hearing or a coroner’s investigation, but it can become overly legalistic and adversarial.

Healthcare workers need to be supported to provide frank information, but we cannot forget about patients and their families, particularly parents of children, who may be experiencing unimaginable grief and distress. Ensuring they are supported appropriately through this process and receive open communication and an acknowledgement of errors from health services is critical as part of their grief journey. This is an area where significant improvement could be made and more guidance and support provided to hospitals about how to do this.

We want a system that aims for full and open disclosure. That is, when a mistake is made, the health service and workers discuss it openly so we can learn from what went wrong. A punitive system that creates fear and shame will not prevent adverse events from happening. Indeed, it will only make them more likely. We also need a functional system in place to support this and to identify where there may be broader system problems. These processes, these sentinel event systems, need to be adequately resourced both at the health service level and at the departmental level. Funding towards safety and quality improvement is enormously offset by the benefits. Even a 1 per cent reduction in preventable adverse events in our health service would save millions of dollars. Not only that, it would significantly reduce the human cost that is currently felt by too many patients and their families.

In closing, we will be supporting this motion before us today. We agree that a review of our sentinel event system is warranted. I am heartened to hear from the government that a lot of work is already underway in this space, and we look forward to continuing to see the outcomes of that.

Melina BATH (Eastern Victoria) (16:25): I rise today to address a very serious matter, and that is the alarming increase in sentinel events in Victorian hospitals. I thank my colleague the Shadow Minister for Health Ms Crozier for bringing this to the house’s attention to enable us to have a respectful debate on what is a very serious issue with far-reaching and lifelong consequences for some families.

Noting the history – I came in here in 2015 – I think it was around 2015 or 2016 that there was the Bacchus Marsh scandal or the Bacchus Marsh sadness. Indeed Safer Care Victoria was born out of a number of sentinel deaths at that hospital, and there was certainly evidence that there was a health system in crisis that needed to have a forensic investigation and continuous improvement, as we often hear ministers talk about in this place, to stop preventable deaths.

Every statistic that we have spoken about so far represents a Victorian family that has been devastated by a tragedy that could or may well have been prevented. If we look at this and the data – I understand this is the most recent data, but it is old data from 2022–23 – again I concur with my colleague Ms Crozier that we do need the latest data. We heard from the previous speaker on the government benches about transparency. We certainly do need to see the most recent data. That would either provide a more positive response and outcome or it would mean that the government has to double down on its efforts and indeed accept Ms Crozier’s very important recommendation at the end for an inquiry into how these events occur and her call for reporting and investigation of these sentinel events.

We saw that in 2022–23, 245 sentinel events were reported across Victoria, an increase on the previous year. It is certainly concerning that deaths increased to 167, up from 155 the year before. So sentinel events and then deaths had increased from the year before, and medical and medication errors skyrocketed by almost 100 per cent in just one year. Then only 23 per cent of these events were reported within a three-day window, again showing and reflecting the workload and the stress that are occurring in our Victorian hospitals. The government absolutely needs to take responsibility for this and double down on the support for our healthcare systems, our hospitals and our nursing and specialist staff.

We saw that about 25 per cent of event locations were in the wards, 20 per cent in emergency departments and 10 per cent in operating, and in intensive care units again around 10 per cent. I want to be quite open about the discussion around Latrobe Regional Hospital. It is something that my family has used, as have so, so many of my constituents, because it is a catchment for basically all of Gippsland. We have used our Latrobe Regional Hospital over many years, and indeed there are some outstanding comments about tremendous quality of care, tremendous service and tremendous nursing and doctor support. There are some that are far less than that, and I am going to speak about some of those today.

Latrobe Regional Hospital reported nine sentinel events to Safer Care over the past five years. We have again heard that this is one example of multiple hospitals that are facing these sorts of issues, so in one way it is a test case for our discussion today. Certainly these are not just stats. They are stats, but they are not just stats – they have humans and losses behind them. Four of the patients allegedly died due to delayed care and two patients suffered severe post-operative complications resulting in serious lifelong disabilities. Indeed there has been documentation that shows that in at least one of those fatal incidents somebody on the ward described the ward as being in chaos. We also have heard discussions from staff around understaffing and a lack of access to basic equipment like computers and pathology services, and medical professionals at Latrobe have raised serious concerns about inadequate clinical experience of staff, lack of education provided to doctors and insufficient training for medical personnel.

Ms Crozier has already read in some of the comments from patients regarding experiences at Latrobe regional that were provided to her under freedom of information. Some staff apparently were not interviewed who should have been interviewed, the contention is, by Safer Care Victoria. It completely suggests a potential gap in the investigation process. Why weren’t these people actually interviewed, and their experiences and their suggestions and improvements taken on board?

There is a public statement from chief executive officer Don McRae, who I know is working very hard on every level, but I will put this on record for balance and transparency. Don said:

Seven cases were reviewed by Safer Care Victoria following a complaint. Four of the patients had died… None of the cases were considered a ‘sentinel event’, which is a preventable serious safety event resulting in the harm or death of a patient.

Each of the cases was reviewed internally by clinical committees at LRH, as is the usual practice. These reviews were undertaken to identify gaps in care and possible improvements.

A subsequent review and a site visit by Safer Care Victoria (SCV) identified the opportunity for quality and safety improvements in our surgical program. Many of these were already underway prior to the review …

said Mr McRae. Then he goes on to finish with:

It also highlighted areas for improvement which we had not considered. These observations are beneficial.

He goes on to talk about continuous improvement. As I said, at the end of every one of these events is a grieving relative, and over time I have had conversations with some of them. For privacy I certainly will not be drilling down into our conversations, but I think there are also other broader issues in relation to protective services and how they operate, and the transfer of patients into hospital. My understanding, from some of the incidents that I have spoken with family members about, is that this is a completely overworked system – we have fantastic staff, but an overworked system. That is something that we can certainly improve – something this government must and should improve.

The Australian Medical Association of Victoria president Jill Tomlinson says Victorians:

…need and deserve transparency…

and that –

This type of data –

that we have been reviewing today –

needs to be readily available so that we can have the transparency required to achieve safe healthcare …

That is what this motion today is about, and that is what this government should be focusing more on. She noted that members have frequently raised concerns about safety within the Victorian care system, and the government’s silence speaks volumes about their priorities.

Again I want to thank Ms Crozier. Behind every statistic is a Victorian family that has been devastated. Families need to feel trust. This whole system, this whole conversation, is around building trust – building capacity in the system so patients’ families can have that trust and are not taking children and burying infants and loved ones. This needs to happen. This government should undertake an independent inquiry into the reporting and investigation of sentinel events, and I thank Ms Crozier for raising this very sensitive, very serious but very important issue in the house this afternoon.

Ryan BATCHELOR (Southern Metropolitan) (16:35): I am pleased to rise to speak on Ms Crozier’s motion with respect to sentinel events and their reporting in Victoria and how we ensure that our healthcare system, particularly our hospital system, delivers high-quality patient care and that Victorians who need medical support, need medical attention and need health care have access to high-quality, world-class care delivered by hardworking, well-trained clinicians and support staff.

At the outset I think it is important to acknowledge that sentinel events, whether they are causing death or serious harm, obviously have significant effects on patients and their families, but they also deeply affect the healthcare workforce that are around and trying to support that patient. I do not think anyone who engages with a member of our hardworking healthcare workforce would in any way doubt that they are always striving to do their best to deliver the sort of health care that is going to make the patient in front of them better. That is why they go to work every day, and they are just as devastated by events when things go wrong as the families and loved ones. In the context of this debate, I think it is worth us acknowledging that too, that our healthcare workers – our doctors, our nurses and the rest of the healthcare workforce – go to work to try and help people. Sometimes they are not successful in alleviating the conditions that are causing injury or pain. Sometimes they are not able to prevent death.

The sentinel events regime is designed so that the system can understand and learn from mistakes that are made. That culture of continuous improvement, that culture of learning and acknowledging how things could have been done better, how particular sets of circumstances led to serious and unfortunate outcomes, is critical to a high-functioning healthcare system – not just the quality of the care that is provided but the quality of the learning when something goes wrong.

In Victoria at a systemic level we have, through the work of Safer Care Victoria and the reporting that is done and through the structure of our sentinel events notification system, some world-class quality assurance and continuous improvement mechanisms. I also do not want to lose sight of that – at a system level we have got some of the best and most robust features to ensure that culture of continuous improvement. The culture of high-quality learning from mistakes that occur at a clinical level is translated through to the system level as well. That is what the role of Safer Care Victoria is designed to do.

We know that there are a range of things that happen in healthcare settings, particularly in our hospitals, that, when they go wrong, we need to understand why. There are 10 sentinel events that are notifiable under the national scheme, the Australian Sentinel Events List, such as surgical procedures that are performed on the wrong site resulting in serious harm or death, or on the wrong patient, or when the wrong procedures are performed. There is the unintended retention of a foreign object following surgery, or the wrong blood transfusions are used. There is suspected suicide in an acute psychiatric unit. There are medication errors resulting in serious harm or death. There is the use of mechanical or physical restraints resulting in serious harm or death. There is the discharge or release of an infant or child to an unauthorised person, and there is the use of an incorrectly positioned gastric tube resulting in serious harm or death. They are the 10 national events.

In Victoria we go further. The Victorian system uses an additional measure to identify sentinel events that need to be reported. Already, at a systems level, our system is above and beyond where our national standards are. We have an 11th category for sentinel event notifications here in Victoria; they are all adverse patient safety events resulting in serious harm or death that are not included in the other 10 categories. I think that additional element speaks somewhat to the seriousness with which the Victorian system takes these matters.

We know that for every system we set up – and this system was established in Victoria after the terrible events that occurred in Bacchus Marsh – like I said, the system is learning, the system is trying to get better and to set up this sentinel events reporting regime. If there are some healthcare professionals and services that are not fulfilling their obligations to report sentinel events in a timely manner, that is of concern to us. The Minister for Health has directed Safer Care Victoria to provide urgent advice on how reporting obligations can be further strengthened and will continue to consult with the AMA on measures that can be further undertaken to improve our systems and processes.

We know that if you espouse the principles of continuous improvement at a clinical level and at a systems level, then you have got to back that up with action that results in those systems continually improving. Again, if we do have circumstances where there has been under-reporting, the minister very clearly thinks that is not acceptable and has asked Safer Care Victoria to provide urgent advice on how those reporting obligations can be further strengthened, in consultation with the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, particularly in relation to child deaths. The medical system does – and healthcare professionals, particularly doctors, do – go through a process of doing regular audit meetings of their work to understand and assess where they could have done things better. They do have, and high-quality clinical care does involve, the practise of using morbidity and mortality meetings for review, in an open, honest and collegiate space, where peers come together to admit where things went wrong and discuss how to make them better.

Both of those elements are important in the healthcare system. Every adverse event, every serious harm, is absolutely regrettable and should be avoided. When they are not, there must be a culture in our healthcare system of acknowledgment when something has gone wrong and a commitment to finding out what can be done to fix it. That culture breaks down when people are fearful of speaking up and speaking out. In the conduct of this debate more broadly about serious events, sentinel events, that occur in our healthcare system – and I am not suggesting that the content of the debate today has done this but just more broadly – we do need to be very, very careful in our words and careful in our attribution of blame, for want of better term, so that our clinicians always are supported to admit when they have made mistakes and to figure out what they can do better next time at an individual level, at a collective level, at a unit or clinical level, at a hospital level and at a system level.

That is the kind of attitude and that is the kind of systemic approach to continuous improvement in quality that we need in our healthcare system. That is what is going to keep our patients safe. That is what is going to keep Victoria’s world-leading, nation-leading healthcare system continuing to deliver exactly what it should for all Victorians, and that is high-quality health care.

Renee HEATH (Eastern Victoria) (16:45): I rise to speak in support of my colleague Ms Crozier’s motion. Firstly, I want to acknowledge that we have amazing healthcare workers that every day show up and give their absolute best – workers that are required to work in an overwhelmed and broken system. I also want to acknowledge that any loss of a loved one is absolutely tragic, but when a death is preventable it causes a different type of heartache that will not heal. Healthcare professionals cannot do the impossible, but what we are talking about here is what we can do from a systems point of view and a training and staffing point of view to make life a little bit better.

I also want to acknowledge that I will be talking a little bit about Latrobe Regional Hospital. As Dr Mansfield said, this is not reflecting on individuals or hospitals as such. It is about a system that is broken. I know that the nurses and the staff there are just really incredible people. My sister-in-law did her original nursing training at LRH, and two of my very best friends are nurses there. Latrobe Regional Hospital had three babies die in six weeks. It is absolutely tragic. They included two newborns and an 18-month-old girl with sepsis who did not receive life-saving antibiotics in time. The 18-month-old’s condition was not identified by a junior doctor. The child died while being transferred to Melbourne, and this resulted in an absolutely heartbroken family and an absolutely devastated young doctor.

The 18-month-old’s death was found to be a sentinel event, meaning that it was preventable. This is the latest in a series of deaths and adverse outcomes at LRH in recent years. LRH was investigated by the health watchdog Safer Care Victoria (SCV) over seven deaths at the hospital in 2023. These deaths were classified as sentinel and were reported to the Minister for Health Mary-Anne Thomas in June 2023 and the Secretary of the Department of Health. However, Minister Thomas did not inform the community. One of the cases reported to Safer Care Victoria involved a patient with a ruptured appendix who was not operated on, even though it was a medical emergency, for over 24 hours after presenting to the ED. Another patient died without being seen by an on-call doctor, which staff believe contributed to their death.

In March this year the Herald Sun reported further whistleblower allegations, including negligence and suboptimal care; delays in receiving essential care; inaccuracies in diagnosis and treatment by medical staff; patients waiting 24 hours for surgery despite being in critical condition; concerns about postoperative care; deaths attributed to medical negligence and inadequate patient treatment; unqualified practitioners putting patients under anaesthesia for C-sections and surgeries; chronic understaffing; staff tasked with multiple responsibilities that were beyond their qualifications; millions of dollars spent on new theatres with no-one to staff them; substandard management and safety; and a pervasive culture of secrecy. These are the sorts of things we can be looking at. Whistleblowers have also claimed that more troubling cases, including deaths, have occurred since the original report was made to SCV in June 2023.

In February 2024 the Herald Sun reported that LRH was having issues hiring qualified staff and was so desperate for specialists that management was offering $10,000 a day to fill shifts to keep its surgery program operational. This is a healthcare system at breaking point.

This suggests a planning failure by the government and a systemic resourcing and cultural issue. These types of systemic health system failures disproportionately affect regional Victoria. Other hospitals affected like this include Albury–Wodonga and Bacchus Marsh, but I do want to highlight that in my area and Ms Bath’s area of the Eastern Victoria Region we are very much affected by –

Harriet Shing interjected.

Renee HEATH: And yours too, Minister. We are very much affected by this. Urgent action is required to properly resource regional health and improve the quality of medical care.

I know so much has been covered in this debate, but one thing I do want to mention is some of the comments by Rural Doctors Association of Victoria president Rob Phair in his response to the situation here. Some of his thoughts are these:

[QUOTE AWAITING VERIFICATION]

The regional healthcare system is under extreme stress. This is not a new problem. It has been gradually building, and it has been exacerbated by COVID.

He also said:

There is a significant population shift to regional areas and this happened a lot during COVID, and the resources needed to cope with this growth have not caught up.

I have been talking about this often, not just the Latrobe regional area but when it comes to the Pakenham hospital. It is one of the fastest growing areas in the country, yet we have not had the healthcare infrastructure catch up with this, and people are really suffering because of it.

Anyway, back to the president of the Rural Doctors Association’s comments. He said:

We want fair access for our communities to good quality health care. It is not just a matter of more infrastructure and beds, it is also a workforce need. Rural health advocates need to be consulted on their expertise, and it has to be valued by the bureaucrats in capital cities.

He said:

We need a strategic plan at a state and federal level. We need a workforce plan that involves training a local workforce. The kids who grew up in rural and regional areas are the future of our rural workforces. Otherwise we are working through incentives to try to attract overseas and city-trained doctors into rural and regional areas. This is an issue that we have seen, and it is simply not sustainable.

In closing I want to thank Ms Crozier for bringing this motion to the house. I think that it is an extremely important motion that is something that we surely all agree on, and I commend this motion to the house.

Michael GALEA (South-Eastern Metropolitan) (16:53): I also rise to speak on the motion which has been put forward by Ms Crozier today on sentinel events, a very serious topic, and whilst we will disagree – and I will go into a bit more detail shortly – I will acknowledge her for bringing this to the house today because this is always an important thing for us to be mindful of and for us to be talking about. It is a very serious issue.

As with other speakers, to begin with in my remarks I do want to also acknowledge all those people and loved ones of people who have experienced sentinel events. It sounds trite to say, but one instance of harm simply is too many, and it is an unthinkable thing to have to go through. I also do want to acknowledge that we do have an incredible health workforce, arguably one of the best in the world, a tireless health workforce from the very top to the very bottom, the people that work in our healthcare system, including in our hospitals, in our critical care settings, who deliver that outstanding care. Many of us have had recent or not so recent firsthand or at least second-hand experience with that health system and will invariably do so on a number of occasions throughout our lives. Those are the moments when we are at our most vulnerable and when the quality of health care is so important, and that is where sentinel events can come in.

We will be debating, potentially as early as tomorrow, a bill to further strengthen nurse-to-patient ratios. One of the earliest initiatives of the then Andrews Labor government nearly 10 years ago was to implement those critical nurse-to-patient ratios that are so vital in providing that health care to Victorians, in providing that safety and the quality of care, to take one less pressure off the risk of these events happening. The strengthening of those nurse-to-patient ratios I know is something that has been extremely well accepted by the nursing community and the healthcare community. I am very much looking forward to debating that bill in this place, as I say, potentially as early as tomorrow.

Sentinel events are an area – and I do acknowledge that Dr Mansfield acknowledged this in her contribution – that this government has taken very seriously, and indeed it has enacted several reforms. Noting Dr Mansfield’s comments about the need for reporting for the accurate resolution of these events and how blame can be a corroding effect on that, it strikes me as rather ironic to see part (1) of this motion, which is a full-throated accusation of blame. I just take a moment to appreciate the irony of that when we are discussing something that is so important. But this is, as my colleague Ms Ermacora went through before, a topic where this government has invested significantly already. One of the ways we did that was through the establishment of Safer Care Victoria in 2017, the state’s independent safety and quality body. There was nothing in place prior to 2017, so it was the actions of this government that set up the system which now is charged with responding to and, as far as it can, preventing further sentinel events in this state.

Since the establishment of Safer Care Victoria, we have also improved the reporting of health service sentinel events, which in turn improves quality and safety over time. The results of this have been published through the annual sentinel events report. It was also this government that introduced the statutory duty of candour reforms, which came into effect just a couple of years ago in 2022, which implements a recommendation from Targeting Zero. The reforms made it mandatory, following a serious adverse patient safety event, for the health service to openly discuss this with a patient and their family by providing and disclosing a written account to the patient or their family, to formally apologise for the harm suffered and also to provide a description of the health service’s response to the event and the steps taken to prevent reoccurrence. Sometimes, in any profession, accidents will happen; sometimes they can have tragic consequences. But I think that third and final aspect of the statutory duty of candour reforms is so important, because when you talk to bereaved families in any situation, in any scenario, they are so often selfless. Their number one concern so often is, ‘I want to stop this from happening to someone else.’ So these reforms, as part of the statutory duty of candour, which as I say came in in 2022, go a great way to ensuring that families who do have to deal with those unthinkable situations have the benefit of a detailed description of what the health service is doing to stop that happening to someone else’s family member.

We also created Victoria’s first chief quality and safety officer, with powers to undertake safety and quality reviews. In addition, all child deaths are reportable and reviewed by the independent Consultative Council on Obstetric and Paediatric Mortality and Morbidity. The Victorian coroner also examines all reportable deaths when somebody dies unexpectedly during or following a medical procedure. Together these mechanisms act as a combined, robust oversight mechanism of accountability, of safety, and a quality framework which is driving improvement as well as a culture of openness and continuous learning. Again reflecting back on Dr Mansfield’s remarks, the importance of openness is so critical when it comes to preventing future sentinel events.

There is an innate human instinct to want to blame, to want justice, and there are cases where that is the appropriate response. But when it comes to preventing further harm, that sense of openness is so very critical.

On top of these mechanisms, we are delivering significant reform through the Safer Care for Kids program. Announced in August 2023, Safer Care for Kids is a family- and carer-led project to improve health outcomes for children and young people in emergency care. In response to an increased incidence of sentinel events relating to patient deterioration, we also proactively brought together more than 100 healthcare leaders, clinicians, patients and families to consider how we might improve the safety and quality of care for children accessing emergency health care in Victoria. This resulted in three key actions, which are underway.

The first is the mandated use of the Victorian Children’s Tool for Observation and Response, otherwise known as ViCTOR, wherever children and young people have vital signs recorded. This includes refinements to emphasise assessment and family and carer concerns. The second pillar is the establishment of the urgent concern helpline, which provides an escalation process for patients and families of paediatric patients to escalate any concerns about a deterioration in health of themselves or a loved one when they feel that their concerns are not being heard. This has already been trialled at a few hospitals and started at Northern Health last year.

Sheena Watt interjected.

Michael GALEA: Yes, that will be of great interest to you, I am sure, Ms Watt. The third pillar is the 24/7 system of virtual paediatric emergency consultation and strengthening sector awareness of this system, which is accessible via the Victorian Virtual Emergency Department. That is a program that I know many in my electorate have benefited from – one of the many reforms we are putting in place. As well as the significant investment into the physical infrastructure of our healthcare system, which I could probably spend another whole 10 minutes talking about, the implementation of services such as the VVED is critical in relieving some of that pressure on our emergency departments.

To discuss the topic at hand today, sentinel events are an extremely serious and extremely tragic event each and every time they happen. I will conclude where I began, which is to again express the deepest of sympathy for people who have themselves suffered or have had close family members suffer a sentinel event. I also reaffirm this government’s commitment to our healthcare workforce and to empowering them to do the absolute very best they can to deliver the world-class health care that Victorians rely on.

Sheena WATT (Northern Metropolitan) (17:03): Can I begin by echoing the sentiments of sympathy to all those families who have lost a loved one to a sentinel event in our hospitals. It is a tragedy each and every time but never more so than when it involves children. I will take some time to make some remarks here with what is left on the clock but also know that my thoughts are always with the families of those in our healthcare system as well as all our workers, because they must feel that tragedy very deeply themselves. Can I also say that the safety of patients in our healthcare system always will be a foremost priority. I do acknowledge that these are terrible tragedies and the tragedy of sentinel events and their impacts on patients and families should be known.

It is necessary, though, to oppose this motion as it fails to properly acknowledge the considerable progress being made by the Allan Labor government in ensuring accountability, transparency and quality improvement in Victoria’s healthcare system. This motion calls for an independent inquiry, and I hold that that is redundant given the significant measures already in place to investigate and respond to sentinel events.

I, like many others in this house, remember the important work that was done by former minister Jill Hennessy, who created safeguards in our health system, and Victoria has established one of the most stringent oversight frameworks in the country, ensuring transparency and accountability in hospital operations through especially the creation of Safer Care Victoria in 2017, and that really did mark a significant step forward in strengthening patient safety. Yes, I was not actually serving in this place at that time. I had the good fortune to serve the Victorian people as a representative on the board of a hospital, in fact one that mostly dealt with children. The introduction of Safer Care Victoria is well known to me, and I do remember that it came from the really unfortunate tragedy at Djerriwarrh Health Services. I know that the government at that time responded very quickly with some very stringent governance improvements across the entirety of the Victorian system, with a particular focus on clinical governance in the hospitals. It did mean that we had to make some pretty big improvements because there was a lot of work to be done that we inherited from the previous health minister.

But when, only a couple of years later, there were some reforms that came in place around the statutory duty of candour, I had the good fortune to make some contributions on that bill in November 2022, and that was something that I felt very strongly about because it did mandate that health services at that time disclose serious adverse events to patients and their families, provide a written account, offer a formal apology and describe, importantly, the corrective steps that had been taken. This initiative really promotes transparency and ensures that affected families receive direct communication regarding incidents, and it really did I believe continue to foster trust in the healthcare system.

There is a point that has been made about the increase in reported sentinel events. I would like to say that is not necessarily an indication of declining hospital standards. Rather I would suggest that it reflects improved transparency and a culture where healthcare professionals feel more empowered to report incidents without fear of reprisals. Victoria has expanded its sentinel event categories beyond the national framework and introduced an additional category that captures all adverse patient safety events resulting in serious harm or death, and it means that in this state, reporting mechanisms are broader and more comprehensive than those anywhere else, leading to a higher number of reported cases. This really is misleading, and I do want to call that out – to suggest that an increase in reporting equates to a decline in care standards when in reality I believe it demonstrates a commitment to learning from incidents and preventing reoccurrence.

Safer Care Victoria and the Consultative Council on Obstetric and Paediatric Mortality and Morbidity have been actively reviewing and refining reporting obligations. The Minister for Health has directed those bodies to provide urgent advice on strengthening reporting frameworks, and there are ongoing consultations with the Australian Medical Association to further enhance systems and processes. The Safer Care Victoria-led review into Latrobe Regional Hospital following concerns about patient safety exemplifies the government’s proactive approach to addressing issues. Furthermore I must say that the appointment of chief medical officer Professor Andrew Wilson to the hospital safety and quality subcommittee does provide expert oversight and ensures that corrective measures are implemented effectively. Any time we bolster board governance by the appointment of people with a background in and strong commitment to safety and quality in clinical governance it is always a good thing.

Beyond reporting improvements, we have undertaken substantive reforms to improve patient safety and reduce sentinel events. With that view, in August 2023 the Safer Care for Kids program was launched, and it demonstrated our commitment to improving paediatric care through introducing essential measures such as reporting the use of the Victorian children’s tool for observation and response to ensure thorough assessment of vital signs in children, establishing an urgent concern helpline to enable families to escalate concerns about a loved one’s health and implementing a 24/7 virtual paediatric emergency consultation service to provide remote support to healthcare professionals in emergency settings.

There is so much that we have done, but I appreciate that there is more that we can do. That is why the collaborative approach that we are pressing ahead with does ensure that lessons are learned and that hospitals are continually refining their safety protocols.

I would like to acknowledge and thank the health professionals that have bravely stepped up and shared their concerns. We will continue to invest in workforce training and development to drive the enhancements in clinical competency and staff and further improve clinical governance across the entirety of the Victorian health sector. Thank you for the opportunity to make some short remarks on that.

Georgie CROZIER (Southern Metropolitan) (17:11): In summing up, I am pleased that most members in this place have realised the importance of this motion, because it does go to improvements in patient safety and understanding exactly the concerns of clinicians who have raised their concerns, as well as obviously looking at what is not occurring. Whilst there have been some moves made by government to further improve systems, there are still many problems. I have highlighted those in my debate, but I am not sure that all government members heard the debate. In some of these areas – where clinicians are saying there is chaos on the ward, there is understaffing and they cannot access computer systems or pathology – there are systemic issues. That is leading to these mistakes and to terrible outcomes such as child deaths. That is an issue around what is happening in the system, and that is why we need to be reviewing and having a look at what is happening, why these systemic failures are occurring and therefore why these serious issues such as child deaths are occurring.

Unfortunately I know that the government had a lot of speaking points from the department or from the minister’s office or wherever to say what they have been doing, but these numbers are where there is a failure in reporting on time or an increase in numbers. Other members have spoken about the statutory duty of candour – well, that is not always happening either. There are real gaps in the system, and that is why we need to review and look at what is not happening in order to improve the system and to ensure that these adverse events, which often end up in terrible and tragic circumstances, can be minimised. As we have said, you cannot avoid all mistakes or every risk that occurs within hospitals. But when there are obvious issues around reporting or investigations not taking place by the authority that is supposed to be undertaking those investigations then you need to review and have a look at the system and why it is not working. That is what this motion is about. It is about understanding that there are many issues within the system that are not working. There needs to be a review into it so that those numbers that are trending up and increasing – the number of deaths that are occurring that could have been avoided; these are preventable events, let us remember – come down. They do not rise, as they are, they come down – that is what needs to occur in relation to what is happening within our health system.

I do make the point that when you have got clusters or you have got significant areas of concern like we have seen over recent months it is incumbent on the government to act. I do not believe the government has acted appropriately or to the extent that it could have or should have. I think they have been preoccupied with other matters, and they have not been focusing on these important issues. We know the department is in absolute chaos. It is dysfunctional. There is no leadership; our senior executives have left in droves. As a result, you are having a range of issues within the department and that is then obviously flowing out into the broader health system.

That is why I say the government has dropped the ball. They should have been addressing this issue months ago. They should have responded to the concerns of stakeholders like the Australian Medical Association and not let them drift along for months at a time when they raised the concerns as well. That is lack of action. That is factual and correct. These things need to be addressed, and I would hope that members in the house would support this motion so that we can get an independent investigation and look into this very important area that affects our healthcare system and, importantly, affects every single Victorian.

Motion agreed to.