Name withheld (5)

Thank you for allowing me to contribute to the independent review into the COVID outbreak with particular reference to the THS-NW.

At this beginning, I want to stress that this (personal) response is primarily a focus on system issues with a particular focus on whole of organisational behaviour and communication.  There will be others, no doubt who will identify specific issues such as  the wisdom of taking the first COVID positive patients into a poorly resourced organisation when other more suitable options were readily available. They may also raise the occasional lack of availability of suitable PPE or logistical problems associated with making PPE available to the vulnerable. Mistakes were made with some critical decisions eg transfer of patients and staff from a known COVID positive environment to a known COVID negative (private) hospital environment or staff working across COVID positive and COVID negative areas.  It is wise to remember however, that these were extra-ordinary times and there were many correct decisions made.

There were, however, examples where individual performed an amazing job, at a time of great duress. These people will remain un-named, but I will forever remember the herculean effort given by these individuals in the face of great adversity. Great leadership was shown by some, including some junior medical staff who were later to be affected by the COVID outbreak.

I should also point out that this response is one person’s opinions. They will be subject to bias, as will other contributions.

I think it is worthwhile to briefly comment on the prevailing environment that existed before the arrival of the COVID positive passengers from the Ruby Princess to the NW Regional Hospital.

North West Tasmania is the least resourced  yet most highly morbid health region in Tasmania.  The finite resources are shared between the MCH and the NWRH. Over recent years, the Tasmanian Government has understandably put boundaries around expenditure in the Health sector  (and almost all other  sectors). Like other sectors such as justice, police and education, the Tasmanian Health sector generally has struggled to meet demand with the budget available. This fiscal constraint, directed by government, has  forced the health sector to innovate tobudgetry become more efficient and sustainable within budget. Innovation and sector improvement takes both investment and time. Unfortunately, the budgetry constraints have outpaced the sector’s ability to reform and this has led to  demand / supply mis-match with capacity constraints and stressors within the sector that were not present some years ago. It is not at all uncommon for hospital to be running  at sub-optimal efficiency settings, simply because of the mis-match between supply and demand.

The North West has always had challenges because of its rurality, the challenge of recruiting and retaining good quality staff, the high co-morbidities of its community and the need to protect  and prioritise bigger centres with higher complexity of care. It is no secret, that there are extended (admission) waits in Tasmanian’s Departments of Emergency.  This is more frequent now than I have known it to be in the last 25 years. Similary, ICU are unable to discharge patients to the ward as there are no non-ICU in-patient beds available. Elective theatre is delayed or postponed because of bed non- availability. The number of surgical inpatient beds in the North West has more than halved over the last 15 – 20 years. Outsourcing of elective surgery is common.

The NW has had a number of senior management changes in recent times (as has the state of Tasmania). We have a relatively new manager of the hospital, and a CEO that oversees the LGH, the MCH and the NWRH who appears “remote”.  It is my opinion, that senior management has not been particularly connected with the senior clinicians, and management decisions appear to be made “remotely”.  There is known service delivery instability, particularly in the Quality and Safety area. Other areas have been stressed in recent times, with the most stressed area changing from time to time. Many senior clinicians have left in recent times.  It remains, to this day, that there has been no consultation with senior clinicians regarding the proposed (broader) organisational structure for the NW. This non-communication style is “normal” for the THS-NW.  There is a “culture of secrecy” or perhaps a deficit in capability.

The Organisation worked quite hard to put COVID plans in place. I am of the opinion that the plans were as considered as they could be. The escalation plans were (understandably) “high level”, were quite “structured”, and gave appropriate consideration to possible changing scenarios in the Department of Emergency Medicine, Medical Ward and ICU and the implications for other aspects of the hospital (including surgery). At the onset of the “COVID emergency management” there was a strong culture to “manage” decisions and communicate within a rigid command and control framework. The decision-making body was remote, not visible, not approachable, and worst of all “silent” and certainly “aloof”. In a sense, the decision making body seemed disconnected from many of those working with COVID positive patients.

Following the admission of first COVID positive (Ruby Princess) patients, the Escalation Plans, including the communication meetings, were implemented. Face to face meetings with supplementary “zoom” meetings were common. The communication by management within this group was as up-to-date. Historical information was accurately communicated but the information  appeared to lack direction.  The initial decision to keep the meetings as “one-way” briefings to key stakeholders, transitioned to a two-way communication platform once the short comings of the former was pointed out.

It was very obvious that even at the very local level, that this was not a decision-making group. Sensible clinical input arising within this group, could not be readily actioned. There was no meeting authority to action anything. It was unclear to some of the senior clinicians if their “un-filtered” voice was being heard by the remote decision-makers.  Even when there was a need to make immediate decisions to immediate problems, there was no authorisation to do so by any of those present at the meeting (including management).  Senior clinicians felt powerless to help co-workers and patients in need. This remote management system was broken at the start.  The paralysis in decision making was made immeasurably worse by the void of timely directional information coming from the remote decision-making bodies. Seemingly sensible suggestions by experienced clinicians were shut down by the most senior of management. In its place, …silence. Some clinicians (not all) felt abandoned and irrelevant.

Early mistakes were made. For example, there was a feeling among some senior clinicians that the definition of “at risk staff” should be more inclusive and that testing should be made available to a broader number of potentially infected COVID positive staff. This was considered in-appropriate and “non-evidenced based”. Representation by local management to remote decision makers (including public health ) appeared to have no effect. Public health were relying on population based evidence that was found to materially change over time.

I was able to speak to many of the local senior management leaders regarding their experiences during this time, and in particular, to understand their experience in relation to the early management. Almost universally, the reflection is that this was a difficult time, an unchartered extra-ordinary disaster scene. There were many brave decisions made, particularly the decision to decant the NWRH to the MCH. Ultimately, the decision to close down the NWRH was an easy decision.

Many articulated that it was not reasonable to expect an optimal response from a small, rural, resource-strapped health organisation with no experience in this setting. This expectation, I think, is accurate, however I think that the outcome  may have been different if some critical mistakes had not been made.

1. The wisdom in accepting COVID positive patients to a rural secondary hospital under known stress.
2. Failure to adequately manage movement of direct contact health care workers (HCW’s) (who were later found to be COVID +ve) across structural barriers
3. The decision to transfer patients from a known COVID positive NWRH medical ward to a known COVID negative Private Hospital ward
4. The wisdom of isolating senior clinical input from higher level decision making, including critical decision making.  The shutdown and lack of engagement of senior clinicians was obvious. These senior clinicians were used to operationalise decisions already made but they did not appear to be part of the decision making group. It would be wise to understand, that many of senior management making operational decisions, would have had little recency of experience at this lower clinical / operational level. Advice on lower level operations, was instead sought from non-clinical “experts” in this space (including public health, ID physicians and infection control nurses). While these persons do have valuable expertise in this space, good management would have seen this as complimentary to the broader body of clinical advice and not a replacement.

A short time ago, and months after the COVID disaster at the NWRH, the NWRH received a transfer from a known COVID positive Melbourne Hospital. The patient had been a referral from the NW to Melbourne for treatment it could not provide. The patient had two COVID tests in Melbourne before transfer and both were negative.

As the patient was being flown across the Bass Strait,  local managment found that the transferring patient had been co-located with a COVID positive patient at the COVID hospital in Melbourne. The NWRH did not know the result of the second COVID test and there were sufficient concerns to repeat the COVID test after patient arrival. This test performed on a Friday and was  found to be COVID positive on a Tuesday, some 4 days later.

In the last week, and in recent weeks, it has been revealed that there are only 6 rapid tests available to the pathology service in the region of NW Tasmania, far less than the number of available tests elsewhere in the state. I am told that one patient from this COVID positive ward, was transferred back to the clean surgical ward after it was known that the Melbourne transferred patient was COVID positive. This decision to transfer this patient to the Surgical ward, was made without any communication to the Director of Surgery.

There are lots of learnings from the COVID disaster management in the THS-NW. It is important that we learn from these experiences and that we, together, implement measures to make the organisation more resilient to a second stress of this kind.

This recent story I tell, suggests to me while we may have identified many improvements to the organisation over recent months, there remains an environment where important critical issues still have  the appearance of lacking robust clinical discussion/ engagement before management decisions are made.

The decision making leading to the acceptance of this potentially COVID positive patient to a stressed rurally located and resource challenged hospital is not clear. I am of the opinion that subsequent to an elevated risk was known (half way across Bass Strait) that an alternative destination (with better resources) should have been chosen.   Again, our resources remain inadequate with regard rapid COVID testing and a four day turn around for non-rapid testing demonstrates to me that we remain ill equipped to manage these higher risk patients.

There remains an appearance that inadequate collaboration with senior clinicians before local decisions are made. No discussion was held with the Director of Surgery before a patient was transferred from a COVID positive Medical ward to a known COVID negative (surgical) ward. This decision replicates the earlier critical errors that were made when transferring patients and staff between hot and cold areas,  which ultimately led to the closing of both hospitals.

These current issues are the same issues that were present during our response to the first COVID wave and will need a significant cultural change in senior leadership behaviour and communication, if they are to be overcome.