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:

  1. Identify any changes to process or procedure to avoid or mitigate the risk of recurrence of the incident, with specific reference to:
    1. possible learnings from international and national best practice
    2. options that may be available to automate testing processes, thereby mitigating the risk of human error
    3. options for improvement of cross-checking and verification processes used in the testing process
    4. opportunities for strengthening staff training and education and
    5. any other matters identified by the Reviewers.
  2. 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.

Page Updated: Wednesday 20 December 2017
Page Owner: NSW Health