The final independent clinical report into the Women’s and Children’s Health Network Paediatric Cochlear Implant Program has been completed and released, with all recommendations accepted.
NextSense, a nationally recognised service provider for children with hearing loss, has provided individualised reports to 107 families of children who opted to take part in the clinical review. A Perth based audiologist also reviewed five children.
The State Government has now provided the maximum ex-gratia payment of $50,000 to the families of 45 children who may have been impacted, including 23 who were assessed by NextSense.
Of the 45 cases, the earliest was implanted in 2010.
NextSense commenced the independent clinical review in July last year, alongside an independent systemic review into the governance of the SA Paediatric Cochlear Implant Program which found long-standing systemic problems with the service dating back to 2006.
Health Minister Chris Picton ordered the independent systemic review into the program, following an internal review which identified as many as 30 children had potential issues with implant mapping at the WCH dating back several years.
That review was released in August, with the Malinauskas Government accepting all 59 recommendations. The Government pledged to completely overhaul the Cochlear Implant Program, offer impacted families upfront ex-gratia payments and set up a special unit to help them with compensation claims.
The NextSense clinical review summary has outlined seven of its own recommendations to further strengthen the WCHN service. The recommendations are accepted in full and are consistent with the recommendations of the governance review.
The seven recommendations are centred around making improvements to the service models and clinical guidelines, better coordination of multidisciplinary care, increased resourcing and equipment, continuous quality improvement, more robust monitoring of progress and outcomes, and improved safeguards to identify and appropriately respond to issues.
All patients involved in the program from 2006 until August 2023 are eligible for ex-gratia payments of $5,000 for any stress caused, regardless of whether they participated in the independent clinical review.
Families of children found to have mapping issues or who were initially identified as of concern in the WCHN internal review are entitled to a $50,000 ex-gratia payment. The payments have been assessed on a case-by-case basis.
In total, $2.72 million has been paid to families who have participated in the WCHN Cochlear Implant program since 2006 – 45 families have received $50,000 and 94 families have received $5,000.
All the NextSense report recommendations are consistent with the governance review released in 2023, which outlined 59 recommendations to support quality improvement initiatives in the program.
Of these, 39 have been fully implemented and the majority of the remaining recommendations are expected to be completed by October.
Since the issue was recognised, WCHN has recruited six additional staff to the program, including two Audiologists, two Speech Pathologists, a social worker, and a specialist role to support improved communication with patients, families, and external providers.
WCHN has also reviewed all procedures, streamlined processes, improved clinical and family collaboration, and has established best practice expected to be undertaken at every appointment to determine a child’s progress following cochlear implantation. The program has increased training and supervision for staff, including mentoring with Cochlear Implant specialists from interstate.
The work undertaken by WCHN has provided a platform for ongoing collaboration, shared learnings, and education amongst providers at both state and national levels, of this important service to patients and their families.
The State Government has established a Special Purpose Family Engagement Unit to assist families with claims for compensation.
To go even further to identify any potential case, WCHN has offered NextSense reviews to anyone prior to 2006, of which 27 people have taken up this offer and NextSense is reviewing those cases. At this stage there has not been any evidence identified of mapping errors in this cohort of patients.
The NextSense summary report can be viewed on the SA Health website.
As put by Chris Picton
I was deeply upset that over previous decades a number of South Australian children were failed by a public hospital service.
That’s why I ordered an independent review to make sure we received the full picture of what caused these issues going back to 2006. I reiterate our sincere apology to these families who have been impacted over the past two decades.
We are doing the work to fix the problems of the past, with impacted families at the forefront of our mind in everything we do.
I want to assure families that we are completely overhauling the service and sparing no expense or effort to ensure that children can receive safe and appropriate care.
My sincere gratitude goes to everyone involved in this important piece of work into the subsequent NextSense reviews.
Recommendations from these reviews will be adopted in full to improve the service and make sure South Australian children receive the care they deserve.
As put by Women’s and Children’s Health Network (WCHN) Chief Executive Officer Rebecca Graham
I acknowledge the impact that issues with cochlear implant mapping and the ongoing reviews into the program has had on families. We are truly sorry to those families who were affected. This is not the standard of care we expect or that we currently provide at WCHN.
Since being appointed to the position of Chief Executive Officer in September 2023, my priority has been supporting this review, implementing all recommendations, keeping our families informed and ensuring that this never happens again.
We are making certain that our Paediatric Cochlear Implant Program has the right support to provide our families, who are the experts in their child’s care with the highest quality services.
We have recruited six additional team members, including speech pathologists, audiologists, a social worker, and a new Cochlear Implant Navigator, and we will continually strive to provide a comprehensive and contemporary service.
I want to thank all families who participated in the review and those who shared their experiences. These discussions have provided significant learnings which have directly resulted in improvements to our Cochlear Implant program.
The Program today is a stronger and safer service thanks to the improvements being made because of this review process.
As put by Former Australian Chief Medical Officer and chair of the independent committee tasked with overseeing the implementation of the recommendations, Professor Chris Baggoley
Over the last 10 months we have made great strides in implementing the 59 recommendations made in the DHW review to overhaul this service.
Now that the NextSense report has been finalised, we will continue to put the right measures in place so that South Australian families can have confidence in this vital service for children.
As put by Women’s and Children’s Health Network (WCHN) Board Chair Christine Dennis
As the WCHN Board Chair, I would like to offer my personal apologies to all those whose child had sub-optimal cochlear implant program settings.
I thank all families for their much-valued input into the review and assure them that with their support we can create a service that provides the highest level of care for South Australian children.
