Government inquiries into system failures are expensive, time consuming and have an enormous impact professionally and personally on those involved. They are set up to investigate systemic failures in healthcare delivery. Such major failures are different from a single event failure that may capture media attention or be the focus of a coronial inquest. Health system failures that result in an inquiry are distinguished by the scale and magnitude of the breakdown in care. The timescale of the events may stretch over months or years, and there are a number of different occasions where poor patient outcomes (including patient deaths) have occurred as a result of inadequate or unsafe care.

In 2000 the Douglas Inquiry was established by the Western Australian Premier and Minister of Health to inquire into the provision of obstetric and gynaecological services at King Edward Memorial Hospital (KEMH). The final report from the Inquiry detailed 237 recommendations for action to improve patient care and safety.

Inquiries of this type tend to be highly politicised and very visible to the general public The act of the inquiry itself can be viewed by politicians and the community as the remedial action for the problems being investigated. The reality however, is that an Inquiry in itself does not “fix the problem”. Rather, it is the actions and changes that occur subsequent to the Inquiry that will improve an unacceptable situation. There is very little examination given to this aspect .When changes are examined, the focus is inevitably on reporting changes in policies and procedures, management structure or accountability processes. While structure and process changes are vital, they do not necessarily translate into differences of how care is being delivered at the coalface. There is very little reported on the outcome aspect of changes. So, the question of whether an Inquiry has actually made a difference to patient safety or patients’ perception of their care is not addressed.

The paper reports the results of a study undertaken to examine whether there have been significant changes in the clinical governance systems and processes in line with the recommendations of the KEMH post inquiry.

Further information about this conference may be accessed at: http://www.aaqhc2009.org.au/

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