Inquiry under Section 122 - Health Services Act 1997
Terms of reference
The Inquiry is to be undertaken by:
- Associate Professor Howard Slater, formerly Head of Cytogenetics, Victorian Clinical Genetics Services (“the Reviewers”) and
- Dr Chiyan Lau FRCPA, Staff Specialist and Genetic Pathologist, NSW Health Pathology
- supported by Ms Sophie Tyner, Office of the Chief Health Officer, Ministry of Health.
The inquiry shall:
- Identify any changes to process or procedure to avoid or mitigate the risk of recurrence of the incident, with specific reference to:
- possible learnings from international and national best practice
- options that may be available to automate testing processes, thereby mitigating the risk of human error
- options for improvement of cross-checking and verification processes used in the testing process
- opportunities for strengthening staff training and education and
- any other matters identified by the Reviewers.
- Oversee and approve the methodology for an audit of samples tested using the Cytogenetics Analyser at the Westmead Children’s Hospital Cytogenetics Laboratory.
The Inquiry will have regard to:
- the Initial Forensic Risk Assessment
- the Report of the Root Cause Analysis initiated by the Sydney Children’s Hospital Network into the Incident (once completed).
The Reviewers are to provide a Report to the Chief Health Officer by 7 February 2018.