Health Minister Roger Cook has today outlined the Terms of Reference for the Independent Inquiry into Perth Children's Hospital Emergency Department following the death of Aishwarya Aswath.
The inquiry is established under Part 14 of the Health Services Act 2016 and will be undertaken by the Australian Commission on Safety and Quality in Health Care (ACSQHC).
This is a separate entity established under the Commonwealth Government to lead and co-ordinate national improvements in the safety and quality of health care.
The inquiry will focus on the specific factors which contributed to Aishwarya's death in the PCH ED on April 3, 2021, and more generally the approach to clinical governance, risk and adverse incidents at PCH.
This inquiry will also investigate the roles and responsibilities of clinicians, management and the executive at PCH, and their escalation of issues to the Child and Adolescent Health Service Board.
The inquiry team, as appointed by the ACSQHC, will include medical and nursing leads with tertiary hospital experience of paediatric emergency medicine, and members with experience in clinical governance, safety investigations (human factors) and medical administration. A representative will also be nominated by Aishwarya's family.
As requested by the ACSQHC, a WA-based clinician will be appointed to the panel to assist with the WA context. This will be a clinician who has not been involved in this investigation to date.
A report detailing the findings, conclusions and recommendations, is expected to be completed within approximately 10 weeks of the commencement of the inquiry.
The report will be provided to Aishwarya's family, the Child and Adolescent Health Service Board and Chief Executive, and the Director General who will all be able to provide comments on the report. It will then be publicly available once it is tabled in State Parliament.
Terms of Reference
The specific terms of reference have been tabled in Parliament and are as follows:
The inquiry will investigate:
- Any matters raised by Aishwarya's family in relation to the care and treatment of their daughter;
- The conduct of the Root Cause Analysis (RCA), any issues identified by the RCA, and the recommendations made on the basis of those findings;
- The ED's staffing, patient flow model, clinical supervision and education programs (as recommended in the RCA);
- The culture of customer service within the ED in relation to children and their families, particularly those of culturally and linguistically diverse (CALD) backgrounds;
- Roles and responsibilities of clinicians, management and the executive at PCH, and their escalation of issues to the Child and Adolescent Health Service Board;
- PCH's clinical incident management processes, including an assessment of previous SAC1 incidents to identify potentially preventable factors;
- PCH's clinical risk management processes;
- The performance of PCH in relation to safety and quality measures as compared to national peers.
As stated by Health Minister Roger Cook:
"No inquiry will reduce the loss suffered by Aishwarya's family nor the distress of staff involved but is vital we all get answers.
"I directed the Department of Health to initiate this inquiry because it is important that we let this process run its course to better understand what happened to Aishwarya.
"While investigations like these are not a common occurrence, they are part of the procedure in this instance.
"It follows the recent Root Cause Analysis which recommended an independent inquiry of the PCH ED.
"The ultimate goal for everyone is to learn from this tragic case, not only to honour the memory of Aishwarya, but also to restore public confidence in our flagship children's hospital.
"PCH is one of the newest hospitals in Australia and we must ensure it is the best it can be.
"Looking at the health system broadly we can be very proud of our health system and staff.
"I know many staff are hurting over this incident and we will continue to support them to deliver high-quality care to WA's children and their families.
"Now is not the time to pass judgement; we should be calm, sensitive and respectful to all those involved and let this Independent Inquiry progress."
