Inquiry under Section 122 of the Health Service Act 1997

On 19 February 2016, the Secretary of the NSW Ministry of Health, Mary Foley announced an Inquiry under Section 122 of the Health Services Act 1997. The Inquiry related to prescribing of chemotherapy at St Vincent’ s Hospital, Darlinghurst by Dr John Grygiel, a senior staff specialist in Medical Oncology, during the period from June 2012 to June 2015.

Off-protocol prescribing of chemotherapy for head and neck cancers

I, Mary Foley, Secretary of the NSW Ministry of Health do hereby initiate an inquiry under section 122 of the Health Services Act 1997. The inquiry is into issues arising from the dosing of cancer patients under the care of Dr John Grygiel which were not in accordance with the eviQ Protocols, at the Kinghorn Cancer Centre, St Vincent’s Hospital, Darlinghurst, from June 2012 to June 2015 [“the incident”].​

Report on patients treated at
Western NSW LHD
[16 September 2016]

Final Report on
St Vincent's Hospital
[31 July 2016]

Interim Report
[31 March 2016]

Terms of reference

The Inquiry is to be undertaken by:

• Professor David Currow, Chief Cancer Officer and Chief Executive of the NSW Cancer Institute; and
• Dr Paul Curtis, Director Clinical Governance, Clinical Excellence Commission;
• Supported by Dr Tina Chen, Medical and Scientific Advisor, Cancer Information Analysis, NSW Cancer Institute and Mr Paul Gavel, Director Workforce HealthShare NSW.

The inquiry shall:

1. Review the adequacy and/or timeliness of the response to the incident including:
   1. the assessment and management of the clinical risk to the patients identified as directly affected by the incident;
   2. the actions put in place to address or mitigate risk to other patients going ahead and to avoid a recurrence;
   3. compliance with the relevant NSW Health Policy Directives and Guidelines dealing with managing and reporting clinical risks, in particular:
      • Incident Management Policy PD2014_004
      • Open Disclosure Policy PD2014_028
      • Complaint or Concern about a Clinician – Principles for Action PD2006_007
      • Complaint or Concern about a Clinician – Management Guidelines GL2006_002.
2. Review the application of the Cancer Institute eviQ Protocols and any other standardised evidence based protocols at St Vincent’s Hospital in relation to Dr John Grygiel’s patients, and systems in place at the Hospital for monitoring application of the eviQ Protocols.
3. Consider and identify any organisational issues or practices that may have impacted on the adequacy or timeliness of actions or compliance with policies as outlined at paragraph 1 above.
4. Identify any systemic learnings arising from the inquiries in relation to points 1, 2 and 3 above and any areas for improvement in policies, procedures or practices operating at St Vincent’s Hospital or more broadly.
5. Provide a report on progress to the Secretary by 31 March 2016, including any interim recommendations or recommended changes to the scope of this Terms of Reference;
6. Provide a final report to the Secretary on a further date, as directed by the Secretary.
   In order to progress action under paragraphs 1, 2 and 3, the Inquiry may:
   1. consider the independent expert review conducted by Dr Brian Stein, Medical Oncologist;
   2. access the medical records of cancer patients of St Vincent’s Hospital from 2009 to the present.

   As amended 4 April 2016

7. The inquiry is extended:
   1. to include consideration of the information provided to patients directly affected by the incident (and their families) in consenting to treatment by Dr Grygiel, and to consider the impact on those affected patients and their families;
   2. to include cancer patients treated by Dr John Grygiel at St Vincent’s Hospital, Darlinghurst from January 2006;
   3. to review the dosing of cancer patients under the care of Dr John Grygiel at Western NSW Local Health District (and its predecessor) from January 2006, and the application of the Cancer Institute eviQ Protocols and any other standardised evidence based protocols at the Western NSW Local Health District and systems in place for monitoring application of those Protocols;
   4. In relation to 7 (b) (and (c) above, to include consideration of the CiSCat (prior to the availability of the eviQ Protocols).
8. In order to address the additional matters listed in paragraph 7 above, the Inquiry may access the medical records of the relevant cancer patients of St Vincent’s Hospital and the Western NSW Local Health District as required.

   As amended 21 July 2016

9. The Inquiry is to report to the Secretary as follows:
   1. a final report on the matters relating to the dosing of cancer patients treated at the Kinghorn Cancer Centre, St Vincent’s Hospital to be provided by 31 July 2016;
   2. a report on the matters relating to the dosing of cancer patients at Western NSW Local Health District to be provided by 16 September 2016.