3 months ago
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An independent probe into the death of two-year-old Joe Massa at Northern Beaches Hospital has revealed a concerning lack of life-saving critical care cameras over the beds of seriously ill newborns and children that are standard across the state’s public hospitals.
The absence of these over-bed cameras underscored the Frenchs Forest hospital’s broader systemic gaps in critical care, resulting from the hospital’s controversial public-private partnership model, according to a report published on the Clinical Excellence Committee (CEC) earlier this month with no public announcement.
Elouise and Danny Massa holding a pair of their son Joe’s shoes.Credit: Kate Geraghty
The report also found a culture of dismissing red flags when patients were deteriorating, with junior staff being hesitant to raise concerns, delays in triggering emergency protocols, and tension between the financial imperatives of clinical care.
When a child is critically ill or injured in NSW hospitals, clinicians at their bedside contact the Newborn and Paediatric Emergency Transport Service (NETS) to connect them with specialists from the Sydney Children’s Hospital Network.
The cameras provide these specialists with a real-time, bird’s-eye view of the patients and the care they are receiving. They identify if the child is deteriorating, direct their treatment, and determine if they need to be urgently transported to a children’s hospital or a paediatric intensive care unit.
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This support is “standard in public facilities”, the CEC report read.
“The absence of access to [overbed] cameras is particularly concerning,” the CEC report read, and forced clinicians at Northern Beaches Hospital “to either operate without essential support tools or develop independent, often duplicative, alternatives”.
Joe’s mother, Elouise Massa, said she had been trying to piece together the puzzle of what happened to her son at the hospital, but had been missing this crucial piece.
“NETS were called to assess Joe, but due to the lack of cameras, these specialists couldn’t see him,” Massa said.
“How was a state-of-the-art facility allowed to be built by the former [state] government and Healthscope without this capability?”
Joe Massa at Northern Beaches Hospital in September 2024, left, and happily playing at home before he became unwell.
Joe died in September 2024 after the hospital failed to urgently respond to a heart rate in the “red zone”.
The CEC was tasked with the probe in March by the Secretary of NSW Health, Susan Pearce. The commission convened a team of independent paediatric, emergency and clinical governance experts to conduct staff interviews and review the hospital’s operations and policies.
The lack of these overhead cameras at the hospital was emblematic of the public-private model. “NBH does not benefit from the economies of scale offered by NSW Health, according to the report”, the review team concluded.
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Junior staff told the review team that they were hesitant to raise concerns if they weren’t certain and audits found inconsistent use of sepsis pathways and Clinical Emergency Response System (CERS) processes.
“These issues are compounded by variable access to senior clinical support and a tendency to minimise or dismiss red flags instead of triggering appropriate escalation pathways,” the report showed.
“That is true of what happened with Joe,” Massa said.
“The clinical emergency response system was never activated for Joe,” despite his imminently life-threatening presentation, she continued. “Systems and structures need to be overhauled and so does staff culture.”
Staff also told the review team that they had “a heightened awareness” of the financial drivers and performance abatements of the hospital’s PPP model, which could create subtle tensions between financial imperatives and clinical priorities.
In June, the NSW government banned all future PPPs for the state’s hospitals.
NSW’s rapid response program, REACH, was in place, but work was needed to ensure staff and patients knew how to escalate their concerns for deteriorating patients.
The CEC made 13 recommendations, including urgently installing overbed cameras and reviewing ED triage processes and nurse staffing ratios.
Massa thanked the NSW government for conducting the review, but urged them to bring forward to timeframe to implement all the recommendations, some of which have a deadline of 12 months.
“Joe died almost a year ago,” Massa said. “Enough is enough ... the timelines need to come forward.”
The review team found NBH staff had a deep commitment to patient care “despite the challenges faced” and the hospital had taken steps to address identified care gaps, including a new clinical governance and escalation processes, but progress had been uneven.
It found the hospital had taken steps to address identified care gaps, including a new clinical governance and escalation processes, but progress had been uneven and with “structural and cultural challenges continuing to impact the hospital’s ability to embed sustainable improvements”.
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In April, NSW Auditor-General Bola Oyetunji released a scathing report that revealed the hospital’s electronic medical record systems “present quality and safety risks”, which Healthscope and the NSW Health had known about since 2018.
The hospital’s poorly connected dual electronic medical record system was a critical factor in Joe’s death.
Health Minister Ryan Park said the recommendations requiring immediate action – appointing experts to Serious Adverse Event Reviews and communicating their findings to staff – had been done, and NBH was working on implementing the others.
“I want to thank the CEC for their work, and I am confident it will bring about important structural changes in the way care is delivered,” Park said.
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