ACEM statement on Perth Children’s Hospital investigations

The Australasian College for Emergency Medicine (ACEM; the College) is warning against rushing to blame individuals and urging focus on fixing the dangerous whole of healthcare system issues risking patient safety in the aftermath of recent tragic events at the Perth Children’s Hospital.

Following this week’s release of the full root cause analysis report, the College again stresses the importance of addressing systemic issues contributing to this specific tragedy, and across the whole system, to try and avoid similar terrible events in future.

ACEM Western Australia Faculty Chair Dr Peter Allely said, “This has been a devastating event for all concerned”.

“It is vitally important that a bereaved family has the answers they need at this time of unimaginable loss, and we acknowledge further investigations need to occur,” said Dr Allely.

“This event has also hit emergency clinicians incredibly hard, particularly so at the Perth Children’s Hospital.

“It has been particularly upsetting to see that official responses to the report so far have largely overlooked the fact that senior emergency department staff had repeatedly escalated concerns for patient safety in the waiting room and about resourcing in the months prior to this tragedy.

“Frontline staff who had been consistently and regularly raising issues must also be supported.

“There is a sense among all emergency clinicians that a similar tragedy could have occurred at any number of the state’s hospitals because of the major systemic issues contributing to dangerous emergency department bottlenecks and overcrowding which we have been consistently raising for some time.”

ACEM President Dr John Bonning said, “Given the significant patient safety and systemic concerns emergency clinicians have repeatedly been raising at hospital, state and national levels for some time now, the focus must be on identifying and fixing these systemic issues, rather than rushing to blame and punish individuals working in a broken system”.

“Governments and hospital executives have obligations to ensure that hospitals and the public health system are properly supported and administered to deliver the safest possible healthcare to the community.

“This is a terrible tragedy, and more answers are still needed. But, as we have been saying for some time now, major systemic change and improvement is required if similar terrible events are to be avoided in future. Rather than seeking to blame individuals, or single emergency departments, the best way forward is to focus on the entire system and secure the fixes which staff at the frontline have been calling out for.”


ACEM is the peak body for emergency medicine in Australia and New Zealand, responsible for training emergency physicians and advancement of professional standards.

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