Concern the review of colonoscopy access by Southland Hospital surgeons was a punitive exercise was raised with reviewers by the clinical director of the Southern District Health Board’s gastroenterology service Dr Jason Hill.
While Dr Hill is not named in the draft review report, released under the Official Information Act, his title heads an observations report included in the appendices.
In it he says the review appeared to have " breached laws of natural justice, polarised professional groups and placed individuals under significant personal emotional stress".
This led to the perception the review was a punitive exercise rather than a quality improvement activity, "and the manner in which it was administered has done little to dispel this view", he said.
Asked if board management had any concerns about these matters raised by Dr Hill, DHB chief executive Chris Fleming said: " We note the clinical director’s concerns, and remain committed to improving the processes and communication within the teams in the interests of quality improvement and safety."
The draft report, without the appendices, became public after it was leaked in May.
Christchurch auditors general surgeon Phil Bagshaw and gastroenterologist Steven Ding, in their call for urgent changes, said limiting access to colonoscopy had gone too far and there was evidence this has had "adverse consequences for patient care".
Mr Bagshaw and Dr Ding were brought in late last year to review Southland Hospital surgeons’ complaints, made over about five years, regarding restricted access to colonoscopy and continually deteriorating relationships between Southland staff and the gastroenterology department at Dunedin Hospital.
The surgeons were upset at the strict adherence to the criteria for access to colonoscopy introduced in 2012. All referrals were assessed in Dunedin and the criteria applied regardless of who referred the patients. They considered they should be able to override the criteria in cases where they had clinical concerns.
Since mid-May, DHB management has moved to allow this. The Southland doctors’ Dunedin counterparts already had the override ability. Mr Fleming said the reasons for the difference were unclear to him. The auditors said some of the cultural and interpersonal issues within the gastroenterology department and with staff in other departments " have been known to SDHB management for years and were thought by some hospital clinical staff to have impacted on patient care".
The reviewers said most of the seven Southland Hospital staff they interviewed showed signs of distress and some were on the verge of tears. The draft report recommended clinical and management staff should be offered trauma counselling immediately.
In his report to the review, Dr Hill questioned a 2016 call for him to be excluded from the review process, the rationale for Mr Bagshaw’s nomination, the process for setting the terms of reference, and why details of cases of concern were not provided to the gastroenterology service by the Southland Surgical Service before an external review was initiated.
He said there was no doubt there had been a breakdown in relationships which had placed the Southland endoscopy service at risk.
There did not appear to be the same level of "robust and standardised processes" in place within the surgical service compared with other services and this was a fundamental source of tension which needed to be resolved.
The difference in approach was further seen in the "apparent unwillingness" for the Southland surgeons to use DHB mechanisms for raising incidents and " the suspicion that is generated when this mechanism is used to raise a concern regarding their service". It was crucial the surgical service understood and accepted DHB procedures for raising concerns " in a transparent and non-punitive manner as this would also avoid potentially polarising situations".
Dr Hill also provided a summary of the service’s internal audit of 90 Southland cases. The case list was provided to the service in late November and he said these cases formed the basis of the Bagshaw-Ding review. The service’s audit had been carried out "without prejudice or bias" as a quality improvement activity. He said this did not support the perception that implementation of clinical access criteria had had any demonstrable impact on missed cancer rates or delays to diagnosis.
"In contrast, cases managed outside triage process were more likely to experience delays in the diagnostic pathway and may have undergone less appropriate investigations."
It was of serious concern that cases of perceived delay or missed diagnosis were not raised promptly, he said.
Understanding why this occurred required clarification to avoid potential for future clinical risk to the surgical directorate and the DHB.
Dr Hill’s audit team found 43 of the cases did not have a cancer diagnosis at the time of the audit and 70 did not have a delay to diagnosis identified. He said it was unclear why they had been included in the list of cases.
He drew attention to the flagging of 34 cases by one Southland surgeon when his team found 32 of them did not have a delayed diagnosis.
It is unclear what weight, if any, Mr Bagshaw and Dr Ding placed on Dr Hill’s audit summary. Their audit of 20 cases found that 10 of them had incurred undue delay in diagnosis or treatment. Mr Bagshaw said he did not wish to comment on any matters to do with the report at this time.
Dr Hill suggested changes, including reviews of Southland’s on-call system for general surgery and the outpatient referral process, and developing better strategies for resolving misunderstandings or differences of opinion.
