Almost 10 years after becoming the face of SA Health's infamous "chemo bungle", Andrew Knox has criticised the south Australian government for not doing enough to prevent more grave medical errors. The scandal saw 10 cancer patients receive half the chemotherapy dose they should have, and at least four are known to have died. A decade on, Mr Knox says the system for raising medical issues remains flawed and is continuing to put lives at risk. While SA Health has told the ABC it's now looking to make changes, it maintains the current model is fit for purpose.
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00:00Andrew Knox is a leukaemia survivor and the victim of one of South Australia's most shocking
00:08medical scandals.
00:10My life is completely bound up with medical appointments. I've had 16 significant operations
00:17and procedures since the bungle and more to come I think.
00:23Mr Knox believes his life today would have been very different if not for a terrible
00:28error that was made 10 years ago.
00:31Because I didn't have any mutations, the evidence was I ought to have been cured.
00:40The 75-year-old was one of 10 patients given only a single daily dose of a chemotherapy
00:46drug when they should have been given two.
00:48The result of that was that all were doomed to relapse.
00:53The chemobungle was discovered at the Royal Adelaide Hospital in mid-January 2015, but
00:59Mr Knox continued to be underdosed at the Flinders Medical Centre.
01:04They issued about 40 emails saying that they were changing the protocol and according to
01:10the evidence before the coroner, nobody read those protocols.
01:15The deaths of Joanna Pinksteren, Christopher McRae, Carol Baird's father and Bronte Hyam
01:21following their underdosing sparked a coronial inquest which began in 2017.
01:28Just before it began, Andrew Knox underwent a stem cell transplant to save his life.
01:34And after two years of evidence, the deputy coroner Anthony Shappell found the error was
01:39the result of woefully inept clinical governance.
01:43He said the process was sloppy and prone to introduce error and that using email was an
01:49inappropriate and clumsy way to tell staff important information.
01:54The FMC and RAH were behaving as cowboys when lives were at risk.
02:03The deputy coroner also slammed SA Health's incident reporting system known as the Safety
02:08Learning System.
02:10He recommended it be replaced with one that reports adverse events immediately.
02:15Five years on, that hasn't happened.
02:18It's just crashing.
02:19I'm sorry.
02:20I'm not, I just don't understand it.
02:30In 2019, SA Health commissioned a review which found its Safety Learning System was sufficiently
02:36flexible to deliver the changes recommended by the deputy coroner.
02:40But that review also found that clinicians often received a lack of feedback after raising
02:45concerns causing them to become disengaged and frustrated with the system.
02:51The Doctors' Union's Bernadette Mulholland says those issues still exist.
02:56There's that lack of confidence that in submitting a safety event or a safety issue that nothing
03:04gets done.
03:07In a statement, SA Health told the ABC that it's preparing a tender process to consider
03:12a replacement of the SLS as part of its ongoing review of IT systems and says all of the remaining
03:19recommendations have been addressed, including the rollout of a state-wide prescribing system
03:25due to be completed early next year.
03:27It's really important that we have something that's functional, that's timely, that they
03:32can fill out with some ease, that's user-friendly and everyone can use it and there's a resolution.
03:39The fact that people are continually affected, hurt and injured after events are known or
03:48first reported is just totally unacceptable.
03:54Mr Knox says he'll continue to be a voice for all patients within the health system.
04:00The only thing that keeps me going is the hope that what I've gone through can make
04:06it better for other people and I'm just being ignored.
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