New scandals have come to light at Peel Health Campus in Mandurah. Source: The Sunday Times
Whistleblower Ashton Foley says she does not regret speaking out despite losing her job. Source: The Sunday Times
THE handling of patient information at Mandurah's biggest hospital was so shambolic that an elderly man simply collecting test results instead ended up being wheeled into an operating theatre for surgery.
But The Sunday Times can reveal an independent consultant's report detailing the shocking case of mistaken identity and other dangerous errors at the Peel Health Campus was edited to remove the worst examples.
The new revelations uncovered by The Sunday Times will add to the crisis enveloping the privately run, publicly funded hospital at the centre of serious claims of corruption, political intrigue and mismanagement.
For the first time the extent of the potential dangers faced by patients can be detailed.
Ashton Foley, who quit as the hospital's chief operating officer in late September over her concerns about the hospital and who testified to a parliamentary committee about them, said yesterday: "My main reason for coming forward was the fear that someone might die because the systems were so poor."
The investigation of the hospital's information technology systems discovered the handling of crucial patient information was so flawed it created widespread "confusion around which copy of the data is correct, if any".
Patients' personal and medical details were stored in "any number of physical or electronic forms" including "sticky notes", increasing "the potential for error as information is transcribed from one format to another".
"It is hard to define the source of truth for business and clinical information within PHC," warned the Applications Assessment Peel Health Campus in September.
The damning assessment was contained in both versions of the report.
Before the report was edited after a hospital board member objected to the shocking examples described, it also revealed how one patient's gender, date of birth and name spelling had differed in various records, resulting in the creation of a "duplicate record".
"If the patient were to re-present to the hospital, then there would be serious issues in sourcing an accurate medical history for them," it said.
The unedited version of the report also said: "An elderly patient visiting the hospital to receive the results of a test was mistaken for another elderly patient who was scheduled for surgery.
"The mix-up was not corrected until the patient was in theatre and the surgeon realised that it was not his patient."
Emails obtained by The Sunday Times indicate Neale Fong, then a director of the private company, Health Solutions WA, which runs the hospital, wanted the details deleted.
The original report blamed a "lack of processes within the hospital" for the surgery mix-up, and specifically "no formal process to confirm the identity of the patient before sending them for surgery".
The revelations follow Friday's release of a report by a parliamentary committee into the company which examined it overcharging the WA Government about $1.8 million to operate the hospital.
Concerns were also raised about a payment scheme that gave emergency department doctors a "$200 incentive" for admitting patients, in order for the company to claim additional government funding for the extra stay.
The committee called on the Government to establish a "full, independent inquiry" into the operation of the campus.
The committee commended its key witness, Ms Foley, as putting "the interests of the people of Western Australia above those of her own".
During the committee sessions in October, Ms Foley alleged she was pressured by Health Solutions shareholder Jon Fogarty to lodge a false "sexual harassment" claim against a senior Health Department staffer perceived as a "threat" to getting Government approval for expansion.
Dr Fong, a former WA Health Department director-general, joined Health Solutions as a non-executive director in May 2012 and became managing director on September 26, 2012. He had no involvement with the $200 payment scheme which operated from May 2010 to June 2011.
Dr Fong emailed Ms Foley on September 9, when she was still chief operating officer, signalling he wanted changes to the information assessment report. The report, which was commissioned by Ms Foley from an independent consulting firm, stated it intended to examine information technology systems and also provide information to "maximise efficiencies" in the hospital.
But Dr Fong said the incidents, including the surgery mix-up, were "not necessarily in context" in the report, because they were "potentially due to many other issues" than IT.
He told Ms Foley he would "speak" to the company that authored the report about the matter.
Later on the same day as Dr Fong's email, the consultant sent Ms Foley a revised "Final report ready for distribution" minus the examples.
Dr Fong also warned Ms Foley in one email about the report that "we need to be careful about what is said in emails regarding patient safety and quality issues", and told her in another, there should be "no further email traffic" about the matter.
Ms Foley told The Sunday Times she requested the report after reading several disturbing complaints.
"There were significant patient risks that I had identified and unsuccessfully raised to the board on numerous occasions," she said. "An external firm actually came in, to create the report, they spent three weeks on campus, met with 30 stakeholders across the hospital and identified patient risks, patient concerns."
Ms Foley, who called on the Corruption and Crime Commission to investigate HSWA, said: "Not knowing which medical record belonged to a person could mean life or death in an urgent situation."
Opposition health spokesman Roger Cook called for further investigations.
Yesterday, Dr Fong did not deny the incidents occurred and confirmed he contacted the consultant. But he said he did not ask the consultant to remove the incidents from the document, which was "not a final report".
Dr Fong said he instead had contacted the consultant with concerns he had raised at a board meeting about whether the events had been substantiated or were relevant to the report and the consultant removed the information.
"I had a conversation with (the consultant) and asked him whether those issues were substantiated or relevant to IT, or could they have been other things, or are they helpful (to the report), and he agreed and he removed it, not at my request," Dr Fong said.
When asked if he referred the incidents to some other mechanism within the hospital to investigate, he responded: "No, I did not do that."
But he said if the consultant had felt the incidents were important enough to the report he could have delayed its release and checked them, and the hospital management team could have also investigated them.
THE WHISTLEBLOWER
THE woman who lost her career and even had mementos of her dead child searched after revealing serious allegations about Peel Health Campus, does not regret speaking out.
But former PHC chief operating officer Ashton Foley praised by a parliamentary committee for putting "the interests of the people of Western Australia above those of her own" hopes there will be "real change".
Speaking yesterday in her only public statement since the committee's report into the hospital was tabled in Parliament on Friday, she said: "I hope the investigations will not end with the committee's report.
"I absolutely want authorities, like the Corruption and Crime Commission, like the police, looking into Peel Health Campus because I believe they will not only unearth evidence to substantiate the concerns that I raised, but they will likely find evidence of other misdeeds.
"Health Solutions and Jon Fogarty, in particular, need to be held accountable for their actions and their failure to act in the best interests of the Peel community.
"I am quite pleased by the diligence of the committee and with the recommendations they put forward.
"It's bittersweet, though. I would have much rather served in my role in a hospital that provided quality patient care to the community instead of having to report on the misdeeds of its operator."
Ms Foley, a mother of four young children, who has previously worked in senior roles in major companies such as Merrill Lynch, the Pfizer pharmaceutical company and the New York Jets, said the harassment and threats she endured since resigning in September had been "quite frightening for myself and my family".
She said lawyers acting for Health Solutions WA, which runs the hospital and is taking court action against her for going public, searched her home in October after securing a court order, even opening a "memory box" which contained a lock of hair of her daughter Sarah, who died aged 20 months after being born prematurely.
In evidence to the committee about her experience after leaving the hospital, she said: "There have been threatening phone calls. There have been times when I have been followed.
"There have been sticky notes that say 'burn, burn, burn' put on my door. I fully believe that the search that was initiated at my home ... was an attempt at intimidation."
Ms Foley, whose evidence at the committee included allegations about inappropriate payments made to doctors and a culture of harassment, said: "I don't regret blowing the whistle.
"I know that I have done the right thing by coming forward."
