Inquiry under Section 122 of the Health Service Act 1997

On 19 February 2016, the Secretary of the 窪蹋勛圖厙 Ministry of Health, Mary Foley announced an Inquiry under Section 122 of the Health Services Act 1997. The Inquiry related to prescribing of chemotherapy at St Vincent s Hospital, Darlinghurst by Dr John Grygiel, a senior staff specialist in Medical Oncology, during the period from June 2012 to June 2015.

Off-protocol prescribing of chemotherapy for head and neck cancers

I, Mary Foley, Secretary of the 窪蹋勛圖厙 Ministry of Health do hereby initiate an inquiry under section 122 of the Health Services Act 1997. The inquiry is into issues arising from the dosing of cancer patients under the care of Dr John Grygiel which were not in accordance with the eviQ Protocols, at the Kinghorn Cancer Centre, St Vincents Hospital, Darlinghurst, from June 2012 to June 2015 [the incident].

Off-protocol prescribing of chemotherapy for head and neck cancers Interim report
Interim Report

[31 March 2016]

Terms of reference

The Inquiry is to be undertaken by:

  • Professor David Currow, Chief Cancer Officer and Chief Executive of the 窪蹋勛圖厙 Cancer Institute; and
  • Dr Paul Curtis, Director Clinical Governance, Clinical Excellence Commission;
  • Supported by Dr Tina Chen, Medical and Scientific Advisor, Cancer Information Analysis, 窪蹋勛圖厙 Cancer Institute and Mr Paul Gavel, Director Workforce HealthShare 窪蹋勛圖厙.

The inquiry shall:

  1. Review the adequacy and/or timeliness of the response to the incident including:
    1. the assessment and management of the clinical risk to the patients identified as directly affected by the incident;
    2. the actions put in place to address or mitigate risk to other patients going ahead and to avoid a recurrence;
    3. compliance with the relevant 窪蹋勛圖厙 Health Policy Directives and Guidelines dealing with managing and reporting clinical risks, in particular:
  2. Review the application of the Cancer Institute eviQ Protocols and any other standardised evidence based protocols at St Vincents Hospital in relation to Dr John Grygiels patients, and systems in place at the Hospital for monitoring application of the eviQ Protocols.
  3. Consider and identify any organisational issues or practices that may have impacted on the adequacy or timeliness of actions or compliance with policies as outlined at paragraph 1 above.
  4. Identify any systemic learnings arising from the inquiries in relation to points 1, 2 and 3 above and any areas for improvement in policies, procedures or practices operating at St Vincents Hospital or more broadly.
  5. Provide a report on progress to the Secretary by 31 March 2016, including any interim recommendations or recommended changes to the scope of this Terms of Reference;
  6. Provide a final report to the Secretary on a further date, as directed by the Secretary.
    In order to progress action under paragraphs 1, 2 and 3, the Inquiry may:
    1. consider the independent expert review conducted by Dr Brian Stein, Medical Oncologist;
    2. access the medical records of cancer patients of St Vincents Hospital from 2009 to the present.

    As amended 4 April 2016

  7. The inquiry is extended:
    1. to include consideration of the information provided to patients directly affected by the incident (and their families) in consenting to treatment by Dr Grygiel, and to consider the impact on those affected patients and their families;
    2. to include cancer patients treated by Dr John Grygiel at St Vincents Hospital, Darlinghurst from January 2006;
    3. to review the dosing of cancer patients under the care of Dr John Grygiel at Western 窪蹋勛圖厙 Local Health District (and its predecessor) from January 2006, and the application of the Cancer Institute eviQ Protocols and any other standardised evidence based protocols at the Western 窪蹋勛圖厙 Local Health District and systems in place for monitoring application of those Protocols;
    4. In relation to 7 (b) (and (c) above, to include consideration of the CiSCat (prior to the availability of the eviQ Protocols).
  8. In order to address the additional matters listed in paragraph 7 above, the Inquiry may access the medical records of the relevant cancer patients of St Vincents Hospital and the Western 窪蹋勛圖厙 Local Health District as required.

    As amended 21 July 2016

  9. The Inquiry is to report to the Secretary as follows:
    1. a final report on the matters relating to the dosing of cancer patients treated at the Kinghorn Cancer Centre, St Vincents Hospital to be provided by 31 July 2016;
    2. a report on the matters relating to the dosing of cancer patients at Western 窪蹋勛圖厙 Local Health District to be provided by 16 September 2016.
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Current as at: Friday 31 March 2017
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