Inquiries into health care: Learning or lynching?

New Zealand Medical Journal

Volumn 121, Issue 1286, 2008, Pages 100-115

  Paterson, Ron ^a  

^a NONE   (New Zealand)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CANCER INVASION; CANCER SCREENING; DOCTOR PATIENT RELATION; EXPERT WITNESS; HEALTH CARE DELIVERY; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH SERVICE; HUMAN; LEARNING; MEDICAL ETHICS; MEDICAL PROFESSION; MEDICOLEGAL ASPECT; MENTAL HEALTH SERVICE; NEW ZEALAND; PATIENT CARE; PATIENT RIGHT; PATIENT SAFETY; PEER REVIEW; PROFESSIONAL COMPETENCE; PROFESSIONAL MISCONDUCT; PROFESSIONAL STANDARD; REASSURANCE; UTERINE CERVIX CANCER; UTERINE CERVIX CYTOLOGY; WHISTLEBLOWING; GOVERNMENT; INTERPERSONAL COMMUNICATION; MEDICAL ERROR; SOCIAL BEHAVIOR;

DELIVERY OF HEALTH CARE; DISCLOSURE; EXPERT TESTIMONY; GOVERNMENT AGENCIES; HUMANS; MEDICAL ERRORS; NEW ZEALAND; PEER REVIEW; QUALITY ASSURANCE, HEALTH CARE; SOCIAL RESPONSIBILITY; WHISTLEBLOWING;

EID: 59449096579     PISSN: None     EISSN: 11758716     Source Type: Journal    
DOI: None     Document Type: Article

References (57)

1. Copyright for this lecture is held by the University of Otago.
2. Logan M. Nordy: Arnold Nordmeyer: A Political Biography. Wellington: Steele Roberts; 2008.
3. Law Commission. A New Inquiries Act. NZLC R102. Wellington: Law Commission; 2008; p. 4.
4. House of Commons Public Administration Select Committee. Government by Inquiry: Volume 1. London: The Stationary Office Ltd; 2005.
5. See endnote 3 above, p37-38.
6. Peay J, ed. Inquiries after Homicide, London: Duckworth; 1996.
7. Brunton W. The place of public inquiries in shaping New Zealand's national mental health policy. Australia and New Zealand Health Policy 2005;2:24.
8. McIntyre N, Popper K. The critical attitude in medicine: The need for a new ethics. BMJ. 1983;287:1919.
9. Canterbury Health Ltd: A Report by the Health and Disability Commissioner (April 1998). http://www.hdc.org.nz/files/hdc/ publications/otherňterburyreport.pdf
10. Nicholls v Health and Disability Commissioner [1997] NZAR 351.
11. New Zealand Public Health and Disability Act 2000, section 71(1).
12. Health and Disability Commissioner Act 1994, section 10(1).
13. The Report of the Committee of Inquiry into Allegations Concerning the Treatment of Cervical Cancer at National Women's Hospital and into Other Related Matters. Auckland: The Committee; 1988 (Cartwright Report).
14. Cartwright S. Personal Reflections on the National Women's Inquiry and Report. Unpublished observations. Twenty years after the Cartwright Report: What have we learnt? University of Auckland; 29 August 2008.
15. Paul C. The Cervical Cancer Study: Science, the Profession, and the Revisionists. Unpublished observations. Twenty years after the Cartwright Report: What have we learnt? University of Auckland; 29 August 2008.
16. McCredie MRE, Sharples K, Paul C et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: A retrospective cohort study. Lancet Oncol 2008;9:425-34.
17. Matheson C. A Never-Ending Story: Personal reflections on the research programme and the inquiry. Unpublished observations. Twenty years after the Cartwright Report: What have we learnt? University of Auckland; 29 August 2008.
18. Personal correspondence to HDC; 29 August 2008.
19. Hilgartner S. Overflow and Containment in the Aftermath of Disaster. Social Studies of Science 2007;37:153.
20. Duffy AP, Barrett DK, Duggan MA. Report of the Ministerial Inquiry into the Underreporting of Cervical Smear Abnormalities in the Gisborne Region. Wellington: Ministry of Health; 2001. http://www.csi.org.nz/ report/download.htm
21. New Zealand Public Health and Disability Act 2000, section 77.
22. New Zealand Public Health and Disability Act 2000, section 79.
23. Gisborne Hospital 1999-2000: A Report by the Health and Disability Commissioner (March 2001). http://www.hdc.org.nz/files/hdc/ publications/172522_health_&_disability.pdf
24. Southland District Health Board Mental Health Services, February - March 2001: A Report by the Health and Disability Commissioner (October 2002). http://www.hdc.org.nz/files/hdc/publications/ other-southlandreport.pdf
25. Dr Roman Hasil and Whanganui District Health Board 2005 - 2006: A Report by the Health and Disability Commissioner (07HDC03504, February 2008). http://www.hdc.org.nz/files/hdc/ publications/whanganui-dhb-feb08.pdf
26. Adams J. New Zealand Medical Association. Newsletter; 2002.
27. Merry A, Seddon M. Quality improvement in healthcare in New Zealand. Part 2: Are our patients safe - and what are we doing about it? N Z Med J 2006;119:1238.
28. Roberts P. Loyal to the profession of medicine and just and generous to its members. New Zealand Medical Association Presidential Address 2007. http://www.nzma.org.nz/news/PresidentialAddress2007.pdf
29. Capital and Coast District Health Board: A Report by the Health and Disability Commissioner (05HDC11908, 22 March 2007). http://www.hdc.org.nz/files/hdc/opinions/05hdc11908dhb.pdf
30. Health and Disability Commissioner. A tragic case at Wellington Hospital. 12 April 2007. http://www.hdc.org.nz/publications/ media?A%20tragic%20case%20at%20Wellington%20Hospital
31. Ingelfinger FJ. Arrogance. N Eng J Med. 1980;303;26:1507-11.
32. Wong D. Paterson R. Commissioner's Comment: Ovarian cancer and expert advice. NZFP. 2005;31;1:50-2. http://www.rnzcgp.org.nz/assets/Uploads/ NZFP/Feb2005/CommissionersComment_Feb_05.pdf
33. Paul C, Holloway L. No new evidence on the cervical cancer study. N Z Med J. 1990;103:581-3.
34. Health Care Complaints Commission. Investigation Report - Campbelltown and Camden Hospitals - Macarthur Health Service. Surry Hills, New South Wales: December 2003.
35. Minister for Health. Government responds to HCCC Report in Camden and Campbelltown Hospitals, New South Wales Government Department of Health, Newsroom, 11 December 2003. http://www.health.nsw.gov.au/archive/news/ 2003/dec/11-12-03.html
36. Committee on the Health Care Complaints Commission. Report of the Inquiry into Procedures followed during Investigations and Prosecutions undertaken by the Health Care Complaints Commission. Parliament of New South Wales: Report No 2; December 2003.
37. Health and Disability Commissioner, Sack the Commissioner! NZGP. 3 March 2004. http://www.hdc.org.nz/publications/ articles?Sack%20the%20Commissioner!
38. Crown Entities Act 2004, sections 39 and 40.
39. Sedley S. Public Inquiries: A Cure or Disease? Mod L Rev. 1989;52:469-78.
40. Health and Disability Commissioner. Psychiatric Nurse, Public Hospital: A Report by the Health and Disability Commissioner (02HDC08692, 31 October 2002). http://www.hdc.org.nz/files/hdc/opinions/ 02hdc08692.pdf
41. Bismark M, Brennan T, Paterson R, et al. Relationship between complaints and quality of care in New Zealand: A descriptive analysis of complainants and non-complainants following adverse events. Qual Saf Health Care. (2006) 15:17-22.
42. Personal correspondence to HDC; 21 July 2005.
43. See endnote 39 above.
44. Paterson R. Complaints - Toxic Treasure. NZGP. 6 February 2002; p. 8. http://www.hdc.org.nz/publications/ articles?Complaints%20-%20toxic%20treasure
45. New Zealand Bill of Rights Act 1990, section 14.
46. Health and Disability Commissioner. Policy Document - Naming Providers in Public HDC Reports. Operative from 1 July 2008. http://www.hdc.org.nz/files/hdc/Naming-Providers-in-Public-HDC- Reports.pdf
47. PsychwatchNZ: http://psychwatchnz.wordpress.com/
48. Mahon PT. Report of the Royal Commission to inquire into the Crash on Mount Erebus, Antarctica, of a DC10 Aircraft operated by Air New Zealand Ltd. Wellington: Govt. Printer; 1981.
49. Re Erebus Royal Commission; Air New Zealand Ltd v Mahon [1983] NZLR 662.
50. O'Neill O. A Question of Trust: The BBC Reith Lectures 2002. Cambridge: Cambridge University Press; 2002.
51. Walshe K, Higgins J. The use and impact of inquiries in the NHS. BMJ. 2002;325:895-900.
52. Walshe K. Inquiries: Learning from Failures in the NHS? London: The Nuffield Trust; 2003.
53. Hindle D, Braithwaite J, Travaglia J, Iedema R. Patient Safety: A comparative analysis of eight inquiries in six countries - A Review for the Clinical Excellence Commission. Sydney: Centre for Clinical Governance Research, Faculty of Medicine, University of NSW; 2006.
54. Tauranga Hospitals Inquiry: A Report by the Health and Disability Commissioner (04HDC07920, 18 February 2005). http://www.hdc.org.nz/ files/hdc/opinions/04hdc07920surgeon.pdf
55. Travaglia J, Greenfield D, Lloyd J, Braithwaite J. Those who do not learn from history: Untapped learning from international inquiries into patient safety. Unpublished observations. 6th Australasian Conference on Safety and Quality in Health Care. Australasian Association for Quality in Health Care. Christchurch; September 2008.
56. Learning from Bristol: The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995. London: Stationery Office; 2001. http://www.bristolinquiry.org.uk/ final_report/report/index.htm
57. Bismark M, Lamb R, Paterson R, Walshe K. Unpublished observations. Whistleblowers and watchdogs: Exposing major organisational failures in healthcare. 1st Harkness Alumni Health Policy Conference. Bagshot, England; July 2005.