Cancer patients given wrong dose - The Weekend Australian, July 26-27 2008
The independent Delaney Review into the Royal Adelaide Hospital radiotherapy under-dosing incident made 14 recommendations for system changes to address issues identified during the investigation. (Find the report at SA Department of Health - Delaney Review, Sep 2008)
Cancer Voices SA Executive demanded action and raised consumer concerns over the incident at a range of levels including with the media, the Chief Executive of SA Department of Health and Professor Delaney.
The ABC Stateline program presented the ‘Cancer Bungle’ story on 15 August 2008, featuring interviews with Ashleigh Moore and Dept of Health Chief Executive, Dr Tony Sherbon.
Stateline SA, ABC TV - www.youtube.com.au/cancervoicessa
A second independent review was undertaken into the decision by the Royal Adelaide Hospital management, to not notify patients, Central Northern Adelaide Health Service, the Department or Health Minister, when the error was discovered in 2006. The Kowalick Report was released on 25 Nov 08. A further 4 recommendations have been supported by the government, although the report concluded that the response by the hospital's management was "reasonable" based on the information available at the time.
CVSA concerns were reflected in the final reports and recommendations eg. ensuring that all affected patients had been identified, need to address poor management of communication with the patients, and the importance of introducing a Dosimetry Standards Program to regularly, independently check all radiotherapy machines in public and private facilities to raise quality standard systems across the state.
Cancer Voices SA will continue to monitor implementation of report recommendations to ensure they are all implemented in full.