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Update by SGH Following Report of the Independent Review Committee’s Investigation into the Hepatitis C Cluster

17 Mar 2016

Following the Report of the Independent Review Committee’s (IRC’s) investigation, our priority has been to continue to care for the affected patients and their families, and to follow up intensively on the gaps highlighted by the IRC.

(A) Ensuring the well-being of affected patients and their families
The care team at SGH has a long and close relationship with our patients and feels deep regret for what happened.

Since the cases were detected, our doctors, nurses and medical social workers have been reaching out to our affected patients and their families to address their concerns and queries, and provide psychological and emotional support.

SGH has given each patient appropriate medical treatment from the time they were diagnosed. The patients remain under close care of the medical team. SGH will continue to ensure that the affected patients receive the necessary treatment, and will pay for the HCV treatment and related costs.

(B) Ensuring accountability
Following the release of the IRC Report, Mr Peter Seah, Chairman, SingHealth Board of Directors, appointed a Human Resource (HR) Panel to examine the roles, responsibilities and actions of key SGH staff, and assess if disciplinary actions need to be taken.

The Panel was chaired by Ms Euleen Goh, SingHealth Board Director and comprises Ms Yong Ying-I, Permanent Secretary (Public Service Division) and Dr Tan Yew Oo, medical oncologist in private practice.

The Panel carefully examined the roles and responsibilities of key SGH staff, taking into account the findings and conclusions of the IRC report. Interview sessions were conducted with key staff involved to understand their perspectives and rationale for decisions made and/or actions taken. The Panel has completed its work and submitted its recommendations to the SingHealth Board, which fully accepted the Panel’s recommendations.

The Panel recommended punitive and corrective administrative action against staff who fell short in discharging their responsibilities in the Hepatitis C outbreak. The Panel recommended that frontline healthcare staff caring for patients, should be provided every support and re-training, and undertake competency assessment, to ensure that they understand and comply with infection control and cleaning procedures. For 12 staff in leadership positions, including senior SGH management, the disciplinary sanctions meted out include stern warnings and financial penalties, for gaps in their roles in managing the outbreak or in infection control. The affected staff have accepted the penalties.

The Panel also made wide-ranging observations and recommendations to further strengthen the Hospital’s infection control and disease outbreak surveillance and management mechanisms.

Mr Seah said: "I would like to thank the HR Panel for their hard work over the past weeks, and their recommendations. The Hepatitis C outbreak was a tragedy that deeply affected and saddened all of us. What happened has been a hard lesson for SGH. The Hospital will rectify the gaps to ensure that patients receive the best and safest care. We will continue to emphasise patient safety as our highest priority. To this end, we will mobilise people, review systems and strengthen processes.”

(C) Reviewing our systems and processes
SingHealth, SGH’s parent organisation, appointed a Report Implementation Committee to follow up on the IRC’s recommendations and actively review our systems and processes. Ongoing steps taken to improve current infection control measures include:
  • Instituting regular, thorough cleaning and disinfection of potentially contaminated surfaces, with clearer roles and responsibilities for who should undertake the cleaning
  • Introducing enhanced education and training programmes, including curriculum for all new staff
  • Improving supervision and monitoring of practices such as hand hygiene practices
  • Use of needleless connectors hospital-wide.
SGH has started an enhanced hospital-wide infection control education and training programme, with annual online competency assessment. Regular audits will be conducted to ensure compliance.

In addition to cross-institutional audits within SingHealth, SGH also engaged Joint Commission International (JCI) consultants to review the Renal Unit’s clinical processes, including renal transplant and infection control practices. JCI is an internationally reputed organisation that accredits healthcare providers according to rigorous quality standards. The Hospital will make full use of the suggestions and recommendations by JCI consultants in its continuing efforts to enhance practices.

Compliance with protocols is a constant pursuit in SGH. We will continue to work hard to improve our processes. The well-being of our patients and families remains of utmost priority to us and we will continue to strive to do better for our patients.

For media enquiries, please contact:
Junaidah Hameed
Singapore General Hospital
DID: 6321 3553 / Mobile: 8125 1707

Tam Shu Er
Singapore General Hospital
DID: 6321 3407 / Mobile: 9793 3940

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Last Modified Date :17 Mar 2016