In June 2015, Paul Lau died in Macquarie University Hospital, after being admitted for a routine knee operation. In October 2016, a raft flipped over on the Thunder River Rapids ride at Dreamworld. Four people were killed. In a world that is moving towards customers being at the heart of everything, what happened to the focus on governance? Are lives safe on your watch?
Dreamworld
Ardent Leisure Group owns and operates a number of businesses including Dreamworld. The Group also operates Main Event in the United States. As a group, Ardent Leisure has over 3 million customers annually.[1] In October 2016, four people lost their lives on Ardent’s Thunder Rapids Ride at Dreamworld. How could this happen in a company that seemed to have strategy and governance covered?
Prior to the incident occurring, Dreamworld noted that its compliance certificate was up to date with an annual mechanical and structural safety engineering inspection having been completed on 29 September 2016.
Leading up to the incident however, there is a body of information which suggests that Dreamworld procedures and compliance had room for improvement including concerns over equipment operation and maintenance and a public liability claim from a patron, alleging negligence, after falling from one of the other rides. People giving evidence at an inquest (in progress at the time of writing) noted various issues which may have contributed to the incident including no emergency scenario training, no automatic switch to shut down the ride if the water level dropped, lack of or inadequate training, misunderstanding among staff and inadequate monitoring.
At the time of the incident, a Board was in place including directors with vast experience in corporate management including qualifications in economics, finance, commerce, philosophy, media, law and marketing. However, although engineering, repair, maintenance and safety, are all key components of the success of this business, there was no one on the board with engineering qualifications or experience.
In place at the time of the incident and still current, the company noted that:
The Company has a sound Corporate Governance Statement, based on the ASX Corporate Governance Principles. A Safety, Sustainability and Environment Committee (SSE) is in place. It has a responsibility to monitor, review, evaluate and make recommendations to the Board in relation to work health and safety (WHS) issues, sustainability and the environment. The Committee is tasked with oversighting and making recommendations to the Board on matters including operational risk management and maintenance of a safe environment for both guests and employees.
Guest safety is wrapped up in the key business risk of Environmental and Safety Management which covers:
“Contamination, Media / Publicity, Employee Safety, Guest & Contractor Safety”.
For a company that is customer-driven, should guest safety have had more prominence?
In June 2015, Paul Lau was admitted to Macquarie University Hospital for a routine knee operation, hours later he was dead. During the inquest, it was found that Mr Lau had died due to a prescribing error. The anaesthetist, Dr Orison Kim, had entered drugs meant for another patient, into Mr Lau’s electronic record. In doing so, Dr Kim had had to over-ride 22 alerts to enter the drugs into Mr Lau’s chart – not noticing the mistake.
At other points in the event, further opportunities had also been present to address the error:
- Dr Kim received phone calls about Mr Lau having duplicate prescriptions on his chart.
- Dr Kim received phone calls about the intended recipient of the drugs, not having enough.
- The mistake was missed by other hospital staff who did not question the unusual nature of the medication for a non-invasive surgery.
- On checking in on Mr Lau, Dr Kim witnessed that he was using strong pain medication that he himself had not prescribed. There was no record of this medication on Mr Lau’s chart. Dr Kim informed the inquest that he had assumed another doctor had previously prescribed the drugs.
In addition to the errors, Macquarie University Hospital at the time was rolling out a new electronic medical records system (TrakCare). This new system was being used by Dr Kim at the time of Mr Lau’s surgery.
The coroner stated she was satisfied that:
“…..the most likely explanation for how the prescribing error occurred is that…..Dr Kim opened Paul’s TrakCare record to prescribe a small amount of fluids, which he had forgotten to prescribe during Paul’s surgery. Dr Kim then failed to close Paul’s TrakCare record and open [the other patient’s] TrakCare record before prescribing post-operative medications for [the other patient]…..It is clear that Dr Kim failed to exercise proper care, diligence and caution whilst prescribing medication erroneously in Paul’s TrakCare record [at this time]…..”
The coroner also found that TrakCare itself, while it did not cause Mr Lau’s death, did contribute to it in a number of ways and she made recommendations for changes.
Governance
In a time when there is much emphasis on data management and data understanding, one of the coroner’s recommendations for consideration in TrakCare changes really hit home to me:
“The effective use, if any, of font, format, sound, colour and placement for alerts”
How many times is data management software designed by the designers up rather than the user down? Why are graphic user interfaces still so complex that the outcome results in inefficient use at best, death at worst? Where was the governance in reviewing and rolling out the software?
Where are the multi-disciplinary teams, including boards, that need to be in place to manage today’s complex companies and requirements?
Keeping people safe on your watch should be a good enough incentive to monitor, implement and continuously test your company’s governance.
[1] https://www.ardentleisure.com/about-us/ October 2016, now on https://www.ardentleisure.com/about-us/corporate-governance/ December 2017.
Bio:
Annette is a highly experienced certified auditor and award-winning risk manager in the water, environment, policy and mining fields. She has helped utilities implement water safety and risk management plans both in Australia and overseas. She has a multitude of journal, book chapter, books, technical papers, reports and other publications in several fields including bioremediation, biodiversity, microbial ecology, water utility due diligence and risk management. Annette is in demand as a conference and workshop presenter, for auditing of statutory and certified risk management plans, for developing utility risk management plans, ERM consultation and development and as a facilitator for board workshops.
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