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Vanuatu Ombudsman's Reports |
REPUBLIC OF VANUATU
OFFICE OF THE OMBUDSMAN
PUBLIC REPORT
ON THE
MALADMINISTRATION
AT THE
VILA CENTRAL HOSPITAL
18 February 2002
0012/2002/02
---------------------------------------------
PUBLIC REPORT ON THE MALADMINISTRATION
AT THE
VILA CENTRAL HOSPITAL
SUMMARY
The Ombudsman is issuing this Public Report to illustrate how a state service like the Vila Central Hospital can fail to carry out an effective service to the public where proper administrative procedures are either absent and/or not followed. Because of this failure, patients may be deprived of a proper standard of health care delivery as expected.
The Vila Central Hospital (VCH) has a duty to see that patients' files are properly recorded and kept according to the Archives Act of the Republic of Vanuatu. The Management Team of the VCH (formerly headed by Mrs. Michelle Sheehan) had gathered certain patients' file and put them in the former nurses’ common room. This enquiry found that some of these files were less than 15 years old and hence, were not ready to be archived according to the Archives Act. The files that were put in this room were in total disarray in a room that was not secure.
The VCH had requested the assistance of a Medical Records Advisor (MRA) to the hospital to suggest improvements to the current system of storing medical records. The MRA issued a report recommending for improvements to administrative procedures and patient record keeping and management. This report was never acknowledged by the Acting Chief Executive Office nor the Management Team of the Vila Central Hospital and therefore, the recommendations were never implemented.
Following this enquiry the Ombudsman found that the Vila Central Hospital Management may have breached the Archives Act by not ensuring that patients’ files are properly archived as set out in this Act. Secondly, health care may have been compromised to some patients in this way as their files may have been archived prematurely.
The MRA for the Hospital came with the assistance of aid donors. As the VCH Management failed to carry out the recommendations, valuable money and time was wasted in bringing in this advisor to the country. Accordingly, there were no feasible improvements made in the administration of patients' files.
In addition, the VCH has a duty to inform patients of their right to lodge a complaint. The Hospital had issued a Complaint Form to be used by patients but there was not enough public awareness to make patients aware of how to lodge a complaint using the form.
The Ombudsman found that the failure by Vila Central Hospital to ensure that patients used the complaints procedure put in place is in breach of the principles of good governance, accountability, transparency and 'good administrative practice' to service delivery promoted by the Comprehensive Reform Program (CPR).
Based on the above, the Ombudsman has recommended that patients' files are archived according to the Archives Act. The Ombudsman also recommended that the present VCH Management urgently examine and implement the recommendations of the MRA. The Ombudsman also recommended that the VCH carry out an effective public awareness program of their complaint procedures so that patients are aware of their right to complain and how to file a complaint against the hospital.
TABLE OF CONTENTS
1. JURISDICTION
1.1 The Constitution and the Ombudsman Act allow the Ombudsman to look into the conduct of government, related bodies, and Leaders. This includes the Vila Central Hospital, a state service under the Ombudsman Act.
2. PURPOSE, SCOPE OF INVESTIGATION AND METHODS USED
2.1 The purpose of this public report is to present the Ombudsman’s findings on certain administrative practices that were carried out at the Vila Central Hospital that are contrary to certain legislation and national policies. The Ombudsman has also made recommendations so that improvements can be made to the system of administration carried out by the Vila Central Hospital Management Team.
2.2 The scope of this investigation is to establish the facts about why the Vila Central Hospital did not properly archive patients' file, carry out the recommendations of the MRA that attended to the Hospital and to inform patients of their rights. It is also to determine:
2.3 This Office collects information and documents by informal request, summons, letters, interviews and research.
3. RELEVANT LAWS, REGULATIONS AND RULES
3.1 CONSTITUTION OF THE REPUBLIC OF VANUATU
The Constitution gives authority to the Ombudsman to carry out an investigation into a complaint that is received from a member of the public who claims to have been a victim as a result maladministration by a government department. Appendix 'A'.
3.2 OMBUDSMAN ACT NO 27 OF 1998
The Ombudsman Act gives authority to the Ombudsman to carry out an investigation into the conduct of any government agency. The government agency that is being investigated in this public report is the Vila Central Hospital, which is a state service. Appendix 'B'.
3.3 ARCHIVES ACT
The Archives Act states 'that all public archives of the age of fifteen years or over that are evidence of private personal [sic] or property rights shall be transferred to the custody of the Archivist and be deposited in the National Archives. They shall be kept in the National Archives until such a time when they can be destroyed'.
Any person who contravenes or fails to comply with any provisions of this Act commits an offence and shall be liable on conviction to a fine not exceeding VT,100,000. Appendix 'C'.
3.4 GENERAL PRINCIPLES OF GOOD GOVERNANCE
One of the principles of good governance that is in line with the Comprehensive Reform Program (CRP) currently taking place in the country is the knowledge of the right to complain. Citizens who have been subject to maladministration, must know how to make a complaint. Public education is essential so that citizens are aware of this. Appendix 'D'.
4.1 OUTLINE OF EVENTS
4.1 In 1999, the Ombudsman commenced an enquiry into the Management of the Vila Central Hospital following two complaints that were received.
4.2 The first complaint was that patients' files would suddenly go missing from the Hospital especially in case where a patient dies in the Hospital and there are suspicions of malpractice.
4.3 The second complaint was regarding a patient who attended at the Vila Central Hospital on 22 June 1999 around 8:00pm. He had to wait until midnight until a doctor came to examine him. When the Ombudsman made an enquiry into the matter, he requested this patient's file but the Hospital could not find it anywhere.
4.4 On 23 September 1999, the Ombudsman received a reply to his enquiry by the former Medical Services Manager, Dr Lesley Everard. In her reply she stated the following:
Dr Everard also requested that there be a meeting held between the Vila Central Hospital and the Ombudsman's Office to discuss this matter further.
4.5 A meeting was arranged and held on 8 November 2000 at the Vila Central Hospital between the Hospital Management, the Ombudsman and two officers of this Ombudsman.
4.6 On our visit to the Vila Central Hospital on that date, we were advised of the following:
4.7 The former Hospital Adviser, Mr Peter McGregor was negotiating at the time of our visit with a Medical Record Adviser (MRA) to come from Sydney in December 1999 to assess the present management of medical records and to give any recommendations. The MRA would make recommendations for all 5 hospitals in Vanuatu.
4.8 The system in place now is when a file is taken from the medical record room, the person will record it on a board that is in the room. When a file is taken to a ward, it is placed on a trolley that is found in the ward. They are placed according to a number that corresponds to the bed number of the patient. Currently nursing staff is responsible for the files during this time as they do not have a Clerk working in the wards. When the patient is discharged, their file is returned to the medical record room.
When a file goes missing, the following steps are taken:
Medical staff is also discouraged from taking the files home.
4.9 The disciplinary measures for removal of files from the Hospital without the permission of the Medical Services manager or the CEO or staff who lose files are as follows:
IMPROVEMENTS IN THE SERVICE OF THE VILA CENTRAL HOSPITAL
4.10 On 21 November 1999, there was a meeting held between the Ombudsman, two of his officers and Mrs. Michelle Sheehan. Mrs. Sheehan explained the following:
THE MEDICAL RECORDS ADVISOR TO THE VILA CENTRAL HOSPITAL
4.11 On 29 March 2000, the former Medical Services Manager, Dr Lesley Everard advised that the MRA from Australia had arrived the week before. She was initially staying for three months after which her work would be assessed and if there she is required to stay longer then her work permit would be extended. After 3 months, she will prepare a report and make appropriate recommendations. The MRA's aim is to sort out all patients' record numbers, place an appropriate system for filing and update the computer system. At that time, the VCH was also hoping to get some assistance with filing from the Australian Navy Boat that will be coming to Port Vila in April.
4.12 On Tuesday 7 September 2000, two of the officers of the Ombudsman visited the Hospital to follow up on the Medical Records Advisor's (MRA) report and to see the other improvements that the VCH has made since our last visit on 8 November 1999.
4.13 On our visit to the Hospital, we found that there was a new Medical Services Manager, Dr Hensley Garae. The former Medical Services Manager, Dr Lesley Everard is now the Paediatrician in the Children's ward as a result of an internal transfer that took place in May 2000. We had to explain to him about the past meetings that took place between the Hospital and representatives of the Hospital Management Team.
4.14 Dr Garae was, however, able to confirm to us that an MRA, Ms Anne Coote, had come to the Hospital on a three-month contract to improve the record system of the Hospital. He was not sure of the date that she left but it was probably in June or July 2000. Dr Garae admitted that he did not know about any report that the MRA was supposed to prepare. We therefore had to wait and ask the Acting CEO, Mrs. Valentine Ronoleo about this report.
4.15 When we spoke with Mrs. Ronoleo, we mentioned to her that the Ombudsman's Office did not receive a copy of the MRA's report and we do not know what recommendations she had made. Mrs. Ronoleo admitted that she had not read the report so she did not know what recommendations were made.
4.16 Dr Garae stated that there had been a meeting between the MRA, the former Management Team and all the Doctors, about the new record system that would be in place. He mentioned that the former Management Team decided to gather all the old patients' records from the year 1992 and place them in the former Nurses Common Room/Library. Dr Garae stated that in the meeting, he had objected that the records be placed in this 'insecure room'. He suggested the records be archived at the National Archive and raised the fact that they cannot destroy any records that are under 15 years old. In addition, before they destroy any records, the National Archive and the Head of the Department has to give authorization. Dr Garae stated that in his option, the previous Management Team was at fault in this regard.
4.17 Dr Garae stated that when patients ask him about their individual file, and it cannot be found in the Records room, he tells them the truth that the Management Team had decided to discard them. We were able to visit the old Nurses Common Room/Library and we found that the files that the Australian Navy had assisted with were on the floor and they were in total disarray. Some files were open and four cats making themselves at home on top of the files. The files were not boxed but scattered all over the place for anyone to see. The Nurses’ Common Room is not secure as the main door was not locked when we visited. The glass door was also broken.
4.18 Dr Garae also advised that the Management Team that made the decision to move the files to the former nurses’ common room were:
4.19 The evidence that we obtained from our visit to the Hospital on 7 September 2000 is as follows:
5. RESPONSES BY THOSE WITH FINDINGS AGAINST THEM
Dr Garae also stated that he was not 'part of the mess' that took place at the Hospital nor some of his colleagues that are new to the Management Team.
They advised that although they are in the Management Team, they only attend meetings when they need to talk about drugs, supplies, equipment and donation. They both work in the Central Medical Stores, which does not come within the Hospital structure.
However, they are glad that the Ombudsman is pursuing this case because they are not happy about how files were being left in a room and not properly archived. This also brings into question the credibility of advisors to the Hospital. Some of them do not respect ni-Vanuatu.
This is the second incident where files were not properly archived. The first incident was when the French Hospital was closed at George Pompidou and was transferred to the Vila Central Hospital. Many patients’ files were burned.
Mr. Morris went on to advise that in 2000, Mr. Darren Penny who was in the Management Team was going to leave in August of that year so Mr. Morris was asked to be his counterpart to attend the Management meetings. However, he was not part of the Team that made the decision on patient records. He only attended some of the meetings.
Mr. Morris at the time of his response was working in the Out Patient Department (OPD) of the Vila Central Hospital. The issue of the files was affecting their work seriously at that time. Sometimes when there is an emergency the patient’s file could not be located so nurses and doctors did not know the patient’s medical history. Some patients who attended the OPD and who have been long time patients of the Hospital also had their files missing.
5.5 On 29 June 2001, the Ombudsman received a response from Mrs. Leipakoa Matariki and Mr. Gideon Ronoleo on behalf of the Vila Central Hospital Management Team. They raised the following points in their response:
6. FINDINGS
Finding 1: THE FORMER VILA CENTRAL HOSPITAL MANAGEMENT MAY HAVE BREACHED THE ARCHIVES ACT
6.1 The former Vila Central Hospital Management Team that was headed by
Ms Michelle Sheehan had a duty to oversee the day to day management of patients' files so that maximum health care is delivered to
each patient.
In one of these Management Team meetings, a decision was taken to gather all the old records from 1992 and place them in the former Nurses Common Room/Library. The files were placed in this room and were not properly archived. Since some of the files are not old enough to be archived as stated in the Archives Act, the Management Team may have breached section 7(1) (b) of the same Act. This section of the Act states that 'All public archives of the age of fifteen years or over (other than those which under any Act are required to be held in the custody of a specified person or Government office) which in the opinion of the Archivist are of sufficient value to warrant their preservation as evidence of ...public or private personal [sic] right shall be transferred to the custody of the Archivist and be deposited in the National Archives.'
The former Management Team failed to forward patients' files that are over fifteen years to the National Archives to be archived until such a time that they can be destroyed as provided for in section 13 of the Archives Act (see Appendix 'C'). However, the present Management Team is currently making efforts to recompile these files as stated in their response in section 5.5 above.
Finding 2: THE FORMER VILA CENTRAL HOSPITAL MANAGEMENT FAILED TO CONSIDER AND CARRY OUT THE RECOMMENDATIONS THAT WERE MADE BY THE MEDICAL RECORDS ADVISOR
6.2 The former Vila Central Hospital Management Team that was headed by Mrs Valentine Ronoleo had a duty to carry out the recommendations of the Medical Records Advisor, Ms Anne Coote, who is an expert in the field of the administration of patients' files.
The acting Chief Executive Officer (CEO), Mrs. Ronoleo claimed that the recommendations were not implemented because she had not read the report. The CEO did not know that such a report existed until the time of interview with representatives of the Ombudsman.
Such a claim by Mrs. Ronoleo cannot be accepted as she was a member of the Management Team that was formerly headed by Mrs. Michelle Sheehan. Aid donors had assisted the Vanuatu Government in providing an advisor to assist with any improvements to VCH administration and services as well as other hospitals in Vanuatu. For the Management not to consider the MRA's report and carry out the recommendations can be seen as a complete waste of valuable time, expertise and money.
Recommendations by the advisor were reasonable and followed standard hospital procedures. The Management had a duty to follow them to improve the quality of patient care at VCH.
Finding 3: THE VILA CENTRAL HOSPITAL MANAGEMENT TEAM FAILED TO INFORM PATIENTS OF THEIR RIGHT TO COMPLAIN ABOUT HOSPITAL SERVICES.
6.3 The Vila Central Hospital Team, both the former and present one, failed to inform patients of their right to complain about hospital services or carry out enough public awareness on the matter.
When the representatives from the Ombudsman's Office visited the VCH and spoke with some of the patients in the wards, most patients were not aware of their rights to complain. One of the principles of Good Governance that is in line with CRP is that people must be given or made aware of their 'right to complain'. Every person who has suffered an infringement of a right must know that they have a legal right to complain and must know how to make a complaint. Patients at the Hospital at the time of our visit did not know that a 'Complaint Form' existed. The VCH Management had therefore failed to carry out enough public education or awareness on this matter.
7. RECOMMENDATIONS
The Ombudsman makes these recommendations based on the above findings to resolve these matters and prevent them from occurring again in the future.
7.1 The Vila Central Hospital Management should pass all patients' files that are over 15 years of age and are no longer in use, to the National Archives as required by the Archives Act to be archived until such a time when they can be destroyed.
7.2 The present Vila Central Hospital Management must ensure that the recommendations of the MRA are carried out and give urgent attention to this matter.
7.3 The Vila Central Hospital Management must ensure that effective public education is carried out so that public is aware of their right to complain and how to lodge a complaint.
7.4 Charts should be put in all the wards to inform patients of their rights and Complaint Forms should be made available to patients or displayed in a prominent area in the ward.
Dated the18th day of February 2002.
Hannington G. ALATOA
OMBUDSMAN OF THE REPUBLIC OF VANUATU
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8. INDEX OF APPENDICES
Appendix 'A'
CONSTITUTION
ENQUIRIES BY OMBUDSMAN
Appendix 'B'
OMBUDSMAN ACT NO. 27 OF 1998
FUNCTIONS OF THE OMBUDSMAN
11. (1) The Ombudsman has the following functions:
(a) to enquire into any conduct on the part of any government agency.
Appendix 'C'
ARCHIVES ACT NO. 13 OF 1992
CUSTODY AND PRESERVATION OF ARCHIVES
DEPOSIT OF PUBLIC ARCHIVES IN THE NATIONAL ARCHIVES
(b) evidence of public or private personal or property rights or civic rights
shall be transferred to the custody of the Archivist and be deposited in the National Archives.
DESTRUCTION FO ROUTINE PUBLIC ARCHIVES
(a) by reason of their number, kind or routine nature do not in his opinion possess any enduring value for preservation in the National Archives as public archives; and
(b) are nor required for reference purposes in any Government office after action on them is completed, or after the expiration of such period of years from the date on which action on them is completed as may be agreed upon between the Archivist and the head of the Government office concerned.
OFFENCES AND PENALTIES
(b) wilfully or negligently disposes of or destroys any public archives otherwise than in accordance with the provisions of this Act; or
(c) contravenes or fails to comply with any provisions of this Act,
commits an offence and shall be liable on conviction to a fine not exceeding VT.100.000.
(2) Where any person is convicted of an offence under subsection (1), the court convicting such person may, in addition to any penalty imposed for offence, order that that person shall not be entitled to have access to the National Archives for such period as the court thinks fit.
Appendix 'D'
Principles of good governance by Maima Koro,
Project Manager for Good Governance
Good governance is generally defined as the 'manner in which power is exercised in the management of a country's economic and social resources for development'.
9 General principles of governance:
A major contribution to good governance is to ensure that every person who has been, for example, unjustly disadvantaged, or has been subject to the impact of corruption or maladministration, or has suffered and infringement of basic human rights, knows that they have a legal right to complain and know how to make a complaint. What is the use of a right, so important to a healthy democracy if people are unaware of it? Usually it is the poor socio economic groups, disadvantaged by lack of money, or lack of education, or illiteracy, who are most affected by bad governance. Effective public education is therefore essential.
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