Paul Murray (Mooner) wrote this article in The West today. He had been trying to get hold of me for days before but had a wrong number. I spoke to him at length this morning. I want to add the following comments to what he has already written: 1. Yes, I was on the Inquiry panel. But I was the only unpaid member of that panel as I was there as the family's representative 2. All I contributed was arranging meetings with the family via BlueJeans etc 3. I did not want to be involved in the interviews with staff as I wanted them to feel safe in that space 4. I saw the report at the same time as the family did 5. The behaviour of McGowan has been nothing short of reprehensible. Visiting one other family but choosing not to grace us with his presence after seven months of bereavement was pathetic 6. His comments to Parliament were bloody awful. This is in relation to Sepsis and its likely impact on Aishwarya. When did he become a medical expert? 7. He continues to say that staffing on the night was good even after the report said it was "sub-optimal" 8. The Inquiry is believed to have cost around $585,000 9. This is a report that is nothing more than a "Whitewash" 10. We sought permission for the panel members to come here to do the interviews. This was refused by Andy Robertson.
Now for Paul's article: "Paul Murray: McGowan Government’s spin doctors treat us like fool Paul MurrayThe West Australian Sat, 13 November 2021 2:00AMComments
The McGowan Government ministry puts out thousands of media releases and self-promoting publications a year, a veritable blizzard of information about their political activity. On Tuesday, the Premier and Health Minister Roger Cook issued a joint release proclaiming that WA was “expected to safely welcome more international arrivals from November 20, 2021, when it is expected 70 per cent of the population will be double-dose vaccinated.” That wording was interesting because it contained two caveats – the glaring use of “expected” twice, without any factual justification – in the one sentence. An astute observer might conclude the statement was issued because the government was feeling the heat from McGowan’s hermit kingdom approach to fighting Covid-19 and his stated insistence about not fully opening up the State’s borders until we are 90 per cent double-vaccinated.
Several days before, McGowan put out a release inviting everyone in WA to celebrate the Indian festival of Diwali, clearly aimed at the 80 Indian community associations the Premier referenced. The astute observer could ponder that the government was cosying up to the strong local expat and migrant community from the sub-continent, which has been a big supporter of Labor in recent years. Strange then that neither McGowan nor Cook saw fit to issue a statement on that same Tuesday about the long-awaited report into the death from an undiagnosed sepsis infection of seven-year-old Aishwarya Aswath at Perth Children’s Hospital on April 3. The report done under the auspices of the Australian Commission on Safety and Quality in Health Care (ACSQHC) exposed multiple failures in the ED at the showpiece new hospital by both management and staff, particularly in dealing with a culturally and linguistically diverse family, but pointedly held no one accountable, instead focussing on systemic issues.
The government’s response came in the form of a media conference which Cook fronted alongside Health Director-General David Russell-Weisz and Child and Adolescent Health Services (CAHS) new board chair, Dr Rosanna Capolingua, where all three said they accepted the report’s 30 recommendations. But accepting a report’s recommendations doesn’t necessarily mean that anything will be done about them. Brief comments from Cook and McGowan appeared in subsequent media reports, without a formal documented government response for the historical record to the 77-page assessment of the failures that led to the Indian migrant family’s enormous suffering. It is almost de rigeur for significant media conferences to be accompanied by a ministerial statement, but not on this occasion. Similarly, critical reports by investigative institutions, like the Auditor-General or commissions of inquiry, demand a detailed response as part of the accountability process that can be referred to later by anyone wanting to know what resulted from the recommendations. The ACSQHC report criticises PCH management for failing to endorse the damning finding of the hospital’s Root Cause Analysis into Aishwarya’s death, instead merely accepting the recommendations. But once again, accepting recommendations rather than owning the failures, is the official response. The obvious parallel is ignored. Aishwarya Aswath. Credit: Supplied/Supplied For a long time, the McGowan Government has been getting away with airy-fairy promises about fixing the health system without any noticeable progress. Cook was reported saying the government’s response would “honour the legacy of Aishwarya” – whatever that means. It is a bizarre twisting of the meaning of legacy. McGowan’s reported comments again referred to “massively increasing” staffing and resourcing – which both the doctors’ and nurses’ unions have previously disputed – and noted what a nasty disease sepsis was, saying one in six Australians who got it died.
His reason for that latter reflection is unclear, but it does appear to be saying there was a high risk the girl would succumb to such a lethal infection. A 2020 national report by the ACSQHC shows the crude case mortality rate is 119.6 deaths per 1,000 sepsis hospitalisations, but that an almost negligible number of those deaths occur in Aishwarya’s 5-9 years age cohort. Most are in babies and the elderly over 60. So the Premier’s one-in-six reference was bulls**t. An astute observer might conclude that McGowan’s reaction suggests the government thinks it has ridden out the storm and fulfilled its obligations to the grieving family. Not so. A long ministerial press conference might be a suitable short-term media strategy, but it won’t bring about required health outcomes. If there is no detailed official response, there is no established benchmark against which the government’s performance can be measured into the future. The ACSQHC report’s recommendations are somewhat nebulous. But to meet their intentions, solid, measurable actions are required. Governments are very skilled at damage control these days. The public would benefit if they were as good at fixing the problems which caused the damage in the first place. And then there is the other major omission in the process so far: How accountable is the Minister? Well, he’s not. He has avoided the scrutiny. Cook, who is clearly very affable and has lots of important friends, is a protected species. Being a good bloke doesn’t make our hospitals run better. Frankly, time’s up on this Minister. Cook needs a clear set of KPIs – key performance indicators – for his response to the Aishwarya report and a finite time frame in which to meet them. A less complacent Premier would demand them in the wake of such a disastrous failure on a Minister’s watch. Did the inquiry live up to its terms of reference? The very first was to look into “any matters raised by Aishwarya’s family in relation to the care and treatment of their daughter.” But the family’s spokesman, Suresh Rajan – who was on the inquiry panel – says the parents were very disappointed, with the result failing to meet what Cook had promised them.
“The inquiry was about policies and procedures and the Health Department, not about Aishwarya’s death,” Rajan said. “We were looking for closure from this… that hasn’t happened.” This is what Cook said the day he set up the inquiry: “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.” The family says they haven’t got answers and still don’t understand what happened. So how could the inquiry be a success? There was a strong sense of the health club talking to itself in this latest report, unwilling to hold accountable those tasked with making the new PCH showpiece operate effectively. That’s a bit of a constant in WA. And then there’s the killer conclusion in the report that no one seems to want to address: Have we set up the glittering bauble of PCH for failure by making it the one and only place for child health outcomes? “The magnet effect of children’s hospitals on communities beyond their natural non-tertiary catchment and the particular impact of such consumer behaviours on the PED are well recognised,” the report said. “In contrast to the WA situation, in most jurisdictions the system managers have implemented formal, tiered paediatric networks, standardisation of practice guidance and expectations of local health service responsibility, in order to facilitate appropriate care as close to home as possible.” You might call it the Telethon effect. In a three-page letter to Cook when delivering the report, Russell-Weisz boasts of PCH’s “exemplary record” for ED performance, promises to “diligently implement all those recommendations that are applicable” – suggesting some are not – and politely refrains from asking for any extra resources. “The DOH and CAHS will update you regularly on the implementation of the recommendations as they are implemented within CAHS and the broader health system,” Russell-Weisz told the Minister. How about also detailing to the public what you intend to do? The latest report was all about “customer service” so why leave them out of the ongoing process? Why aren’t we being told what will be done? Would the roadmap further expose embarrassing issues? Perhaps it’s because a lot of the problem is about hospital staff numbers and fixing that issue is contingent on the State borders being opened – a key criticism in the report. Much of the media seems to have swallowed McGowan’s line that we will routinely hit 80 per cent double vaccination by the end of January when he will deign to give us an opening date based on a further guess about hitting 90 per cent. There’s that double caveat again. Will those who have been resisting vaccination be likely to get inspiration to do the responsible thing over the long festive period ahead? You’d have to believe in Santa Claus. And the government is probably hoping that by the end of the holiday period everyone has forgotten about Aishwarya and can’t recall what the government said – or didn’t say – it intended to do about her death."
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