Alarming rise in the number of sentinel events at public hospitals, Productivity Commission Report shows

31 January 2020
A report on public hospitals has identified an increase in sentinel events that cause serious harm to patients, with rates of inpatient suicides, incidents involving retained instruments or other material after surgery and medication errors leading to death continuing to put patients and their safety at risk, according to Maurice Blackburn Lawyers.

The Productivity Commission has today released its Report on Government Services (Health) 2020 that looks at the provision of government provided health services, including public hospitals, for 2017-18.

Maurice Blackburn’s national head of Medical Negligence, Dimitra Dubrow, said the figures were concerning.

“Nationally, the report shows that the number of sentinel events in public hospitals has increased from 65 in 2016-17 to 80 in 2017-18, which reflects unacceptably high rates of inpatient suicides (24 in total nationally), with incidents reported across almost all states,” Ms Dubrow said.

“Victoria, continues to have the highest rates of sentinel events in the country, with 24, which includes seven inpatient suicides in 2017-18, and 12 incidents of retained instruments or other material after surgery, and two medication errors leading to deaths.

“NSW also recorded an increase with 20 in 2017-18 compared to 18 the previous year, while Queensland and South Australia each recorded 11 sentinel events compared to six and five respectively in 2016-17.

“Unfortunately, many of the incidents reported reflect the experiences of our clients, namely preventable events that have caused very serious and unexpected harm during a hospital stay,” she said.

“While this report shows that there is still work to be done to address unacceptable rates of sentinel events, the transparency of the states in reporting such events is welcomed in helping to shine a spotlight on our public hospitals so that issues can be identified to improve the safety of services for patients.”

The report also looks at adverse events at public hospitals – incidents in which harm resulted to a person during hospitalisation such as infections, falls resulting in injuries and problems with medication and medical devices.

“Such scrutiny of our private hospital system is long overdue – we know from the many medical negligence clients we assist that sentinel events are not isolated to the public hospital system and that there are many serious incidents that also occur in the private hospital system,” Ms Dubrow said.

“It is critical that there is greater reporting done across all hospitals to identify patient safety incidents and to ensure that action can be taken as a priority to address these risks.”

Media inquiries: Andrea Petrie at Maurice Blackburn on 0412 655 264 or via

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