IRC report shows escalation and notification process was flawed and needs overhaul

We thank the Review Committee for their hard work in producing a detailed and professional report.

The report identifies gaps in the infection control procedures for Healthcare-Associated Infections (HAIs) at SGH, as well as in the national system for notification, escalation and response. For example:

  • blood specks infected with Hepatitis C Virus (HCV) found on the wall of Ward 67
  • the delays in the SGH renal unit notifying SGH infection control
  • the MOH-CDD’s failure to classify the initial notifications as acute HCV
  • the failure to perform certain elements of investigation before 3 September, which were only undertaken at the request of the Director of Medical Services (DMS) on 3-17 September
  • SGH senior management and some clinicians assuming that SGH was liaising with MOH-CQPT (Clinical Quality, Performance & Technology Division) and that MOH-CQPT would inform the DMS if necessary

This incident contributed to the loss of seven lives. We should take an extremely serious view of such failings and gaps. We welcome the Minister’s assurance that changes will be made to reduce the risk of this incident recurring, and that the issue of accountability of personnel will be addressed by Human Resource (HR) panels at SGH, SingHealth and MOH. We look forward to reviewing the decisions from these panels when these are made public.

The Independent Review Committee (IRC) has made several recommendations for addressing the gaps it identified, such as creating a team within MOH to deal with outbreaks, improving the national notification and surveillance system for acute HCV and strengthening the escalation process for unusual HAIs. MOH has also announced the formation of a Taskforce to review these recommendations and determine an action plan.

The Workers’ Party had called for a Committee of Inquiry (COI) as the best structure to conduct this investigation. A COI would have been more effective than a review committee in making the process of investigation and accountability transparent and thus bolstering public confidence in the face of a very grave failing leading to loss of life. Our call for a COI was rejected. We do not call for a COI at this stage because at the outset, we argued against a two-track process of having an IRC review followed by a COI investigation. Once again, we note that it is not incumbent on anyone calling for a COI as a matter of procedural improvement to allege shortcomings in the IRC process or results.

With regard to the MOH taskforce that has been asked to operationalize the IRC’s recommendations, we urge this taskforce to solicit feedback widely from the medical profession and the broader public. We also recommend that this taskforce be co-led by a respected, retired healthcare professional to ensure that recommendations are formed from a perspective of sufficient independence from the existing organization structure. This taskforce bears a heavy responsibility as MOH is the last line of defence against failures in any healthcare institution.

We make the following suggestions for the MOH taskforce, in the spirit of strengthening our healthcare system and learning the lessons from this incident.

  1. The IRC report calls for a strengthening of the national response and escalation framework for HAIs.[1] It does not spell out in detail what these enhancements should be, which is understandable as its primary focus was on the Hepatitis C outbreak at SGH. There is hence a need for the taskforce to define in some sense what is timely in moving from potential outbreak recognition to escalation, notification and countermeasures. At the level of national systems, there should be a clock that starts ticking from when an infection is suspected to when it is verified, announced and responded to. This is a key issue, since the report notes: “The IRC is of the view that earlier escalation of the matter from SGH to SingHealth, or from SGH or MOH staff to the DMS could have triggered earlier injection of additional resources and expertise to help in the outbreak investigation and management, from across the public healthcare system.” (Pg 49)
  2. The report does not suggest what should be the role of Singhealth, or any other healthcare cluster/group, in an ideal escalation workflow. It noted that SGH did not escalate the issue to Singhealth, with the Group CEO only learning about the outbreak on 3 September after the Director of Medical Services learnt about it on 1 September, and the SingHealth Board being briefed on the incident on 20 September after the Minister was alerted on 18 September. The ideal role of the healthcare cluster/group in such incidents should be taken up by the taskforce.
  3. The report concludes that the time lapse between 3 September when the Director of Medical Services was briefed on the infection, to 18 September when the Minister was alerted, was justified by the need to conduct more investigation to ascertain the severity and extent of the outbreak. In so doing, the report may be setting a precedent and an implicit guideline for the timeliness of alerting the Minister and the public when such incidents happen. Such a guideline should be made explicit for avoidance of doubt in future, as to what sorts of information should be ascertained and what standard of timeliness followed in the flow of information from the Director of Medical Services and Permanent Secretary to the Minister, and from the Minister to the general public.

Leon Perera
Non-Constituency Member of Parliament-Elect
The Workers’ Party

9 December 2015

[1] “Within MOH, unlike community outbreaks, no one division has clear responsibility to deal with outbreaks of unusual HAIs. This hindered MOH’s ability to respond in a timely way to the unexpected event. In addition, the absence of an established framework for unusual and unfamiliar events resulted in delays in escalating the matter from SGH to SingHealth, from SGH to MOH, and within MOH.” (Pg 53)