The Report, produced by the Australian Commission on Safety and Quality in Health Care (ACSQHC), put forward 30 recommendations which have all been accepted by the Western Australia Department of Health and the Board of the Child and Adolescent Health Service (CAHS). The College will be seeking to work with the Department to support their implementation to ensure similar tragic events are avoided in future.
Given the significant patient safety and systemic concerns emergency clinicians have repeatedly been raising at hospital, state and national levels for some time now, the College believes that following the release of the Report, the Department of Health must focus on acknowledging and fixing these issues, rather than continuing to solely blame and punish individuals – or indeed single emergency departments – working in a broken system.  
In particular, the College is buoyed by the Report’s focus on fixing dangerous whole-of-healthcare system issues risking patient safety, particularly with regards to the recruitment, training and retention of the emergency medicine workforce. The College is actively engaging with the Department of Health on workforce-related issues and has been encouraged by its recent acknowledgements of the urgent need for reform in this area.
The Report also makes particular note of the effect of access block at PCH, noting that its Western Australian Emergency Access Target (WEAT) performance demonstrated “efficient performance within the Emergency Department (ED) but highlight[ed] the impact of persistent and increasing access block at PCH… with insufficient hospital wide responses”. The College agrees with the Report’s emphasis on the need to shift responsibility for patient flow to the entire hospital, rather than to simply measure ED performance.
Following this, ACEM will advocate specifically for the swift implementation of Recommendation 14, which calls for enhancements to “the structure, function and governance of the PCH Patient Flow Unit to optimally coordinate patient referrals and flow, including out of hours, with no inappropriate requests for ED to manage non-ED patients”. As issues with patient flow are felt right across the State, the College will also call for such reforms to be implemented across the hospital system.
There is a sense among many emergency clinicians that a similar tragedy could have occurred at any number of the state’s hospitals because of the major systemic issues contributing to dangerous ED bottlenecks and overcrowding. Emergency clinicians are more than aware that ACEM and many FACEMs have been consistently raising these issues for some time.

Governments and hospital executives are obligated to ensure that hospitals and the public health system are properly supported and administered to deliver the safest possible healthcare to the community. To that end, ACEM will keep members updated regarding the implementation of the recommendations from the Report.

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