Questions and answers

1. Individual events or patterns?

Are hospitals failing to report and investigate individual sentinel events, or is Safer Care Victoria losing the ability to detect patterns of serious harm across multiple hospitals? And what evidence is there that either problem has worsened because of the cuts?

Both, and they are linked. At the individual level, hospitals are responsible for investigating their own sentinel events, which they report to Safer Care Victoria, which oversees the process (Safer Care Victoria). In 2024–25 there were 217 sentinel events, 61% involving a death. Only 26% were notified within the required three business days, and reviews averaged 79 and 106 business days against standards of 50 and 75 (Safer Care Victoria, Sentinel Events Annual Report 2024–25).

In my experience, a single sentinel event review typically takes in the order of 100 to 150 or more staff hours, through a structured, systems-focused review such as root cause analysis. That covers a multidisciplinary panel (in 2024–25, 99% of review teams included an external expert and a consumer representative), chart review, staff interviews, duty of candour meetings with the patient or family, and executive sign-off. With less staffing, capacity is reduced. The Statutory Duty of Candour legislation is important for ensuring patients are informed of complications and errors, but in my experience it has also added significant load to these teams without any additional resourcing. The teams are forced to choose which events to prioritise, which in my view contributes to the delays and under-reporting. As a result, I have seen serious events downgraded in severity for resourcing reasons and left unreviewed for months. At the system level, seeing patterns across hospitals depends on data and epidemiology capability, and that is what is being lost.

On evidence of worsening: the official reasons given are themselves about resourcing. This is the issue with statements that “back office” staff are being cut while “frontline” staff are preserved. Safety and quality teams, both in the Department of Health and in hospitals, are often classed as “back office”, even though they have a vital role in supporting frontline staff to provide good care. Specific examples where lack of resources has resulted in cuts to safety and quality programmes that are not covered by any other area of government or hospitals:

• Safer Care Victoria’s severe maternal morbidity surveillance project was paused in September 2024 “due to resourcing constraints”.
• Mandatory hospital quality accounts were permanently ceased, citing “ongoing increased resourcing and regulatory pressures” (Safer Care Victoria).
• By January 2025 the Data Request Hub had stopped accepting requests from anyone outside the department, including health services wanting their own data (archived hub page, January 2025).

It is difficult to show a direct relationship between cuts to safety and quality systems, risk and specific harm. The best analogy I can offer is James Reason’s “Swiss cheese” model, used widely in patient safety. Each slice of cheese is a layer of defence (for example, staffing, clinical guidelines, escalation processes, incident review, data monitoring), and the holes are its weaknesses (patient, care-related and system-related risks). Harm occurs when the holes in several slices line up, and the bigger the holes, the more easily that happens and the more severe the harm is likely to be. Our safety and quality systems are themselves slices: they collect, analyse and report risks, harms and the factors that determine their size, and they investigate and respond to eliminate or shrink the holes, preventing risks becoming harm or reducing its severity. When safety and quality systems are cut, slices are removed and the remaining holes get bigger, and the safety and quality of care suffers.

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2. Why separate data functions in Safer Care Victoria when VAHI exists?

Why are separate data collection and analysis functions needed within Safer Care Victoria when VAHI already exists? Could the data functions be consolidated, eliminating duplication and protecting the specialist clinical investigators instead?

I agree with the principle: consolidate, avoid duplication, protect the investigators. The difficulty is that VAHI no longer operates as the separate agency Targeting Zero intended. It became a business unit within the department in 2021 and now sits within the eHealth division, with an estimated loss of 40% of FTE across the division, including specialist staff who understand safety and quality systems. In early 2025 the department engaged Deloitte for “affordability advice to support the eHealth Division to operate within its approved salaries budget” (DH response to PAEC 2026–27, p. 143), with the division’s former Deputy Secretary reporting there was a 40% reduction in FTE (L. Emerson, LinkedIn).

When the data hub stopped servicing requests other than internal requests from the Department of Health, Safer Care Victoria staff who needed data were redirected to an eHealth business partner and, in my experience, ultimately could not access the data needed to perform their functions. Safer Care Victoria staff proposals during the restructure included exactly this kind of consolidation, and none was accepted. What matters is not where the analysts sit, but that specialist epidemiological and clinical analytic capacity exists, is protected, and answers to the safety agency’s needs.

So, ultimately, I believe a threshold has been reached where specialist skills (epidemiologists, data analysts and clinical investigators) have been lost through staff reductions, and the chief clinical officers have been moved out of Safer Care Victoria, such that the in-house capacity is no longer sufficient. VAHI does not exist in its original form, and in my view eHealth has not retained sufficient expertise or staffing to perform this specialist health data collection and analytical function.

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3. Who investigates a death, and who ensures recommendations are implemented?

When a patient dies because of a suspected medical mistake, who is responsible for investigating it: the hospital, Safer Care Victoria or an independent investigator? And who has the power to ensure recommendations are implemented?

In the first instance, the hospital. Hospitals must report sentinel events to Safer Care Victoria and review them, and since 2022 they owe a statutory duty of candour to the patient or family for any Serious Adverse Patient Safety Event (SAPSE), irrespective of whether it was due to a mistake, or was preventable or unpreventable. Safer Care Victoria’s Chief Quality and Safety Officer can also conduct independent quality and safety reviews, enter premises and require documents and answers (Health Services Act 1988, Part 5A; explanatory memorandum). The coroner investigates reportable deaths independently, provided they are reported. On implementation, Safer Care Victoria can recommend, but the power to act sits with the Secretary of the Department of Health (for example, s 42 directions) and the Minister. I could find no public example of a s 42 direction or a funding consequence for a safety failure. By contrast, budget directions were issued to every board in 2024 (PAEC hearing).

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4. The reported 80% loss of perinatal epidemiologists

How many perinatal epidemiologists were employed before, how many remain, and when were the positions lost?

In Safer Care Victoria, there were 5 FTE perinatal epidemiologists before the first restructures a few years ago, and there is now 1. That figure comes from my own knowledge of the area, not a published statistic. The department publishes no establishment figures for these roles. A question on notice, or a PAEC question asking for perinatal epidemiology and biostatistics FTE by year since 2020, would give exact numbers and dates.

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5. Documented harm versus risk of future harm

What actual patient harm can be attributed to the loss of these capabilities? Can documented harm be distinguished from risks of future harm?

Yes, they can and should be distinguished. What is documented is the loss of capability and the failure of processes:

• late sentinel event notification and reviews (Sentinel Events Annual Report 2024–25);
• severe maternal morbidity that is largely uncounted: about 3.42% of births (Duke et al.), against 257 notifications in 2023 (CCOPMM), so up to 90% may be missed;
• the end of quality accounts (Safer Care Victoria);
• the closure of the VAHI/eHealth Data Request Hub, so that data is not available to agencies external to the Department of Health, including Safer Care Victoria, health services and researchers (current hub page).

Attributing a specific death or injury to a specific cut is not usually possible, and I won’t claim it. What we do know, from Bacchus Marsh, is what happens when detection fails. The national safety commission found the department’s capacity “does not appear to be robust”, while the hospital had received a “perfect score” from departmental performance monitoring that “concerned themselves primarily with budget and activity data”, even though avoidable deaths were occurring (ACSQHC, 2015). The risk is future harm that goes undetected until it becomes a cluster, and Bacchus Marsh shows how hard that is to detect unless you have the systems in place to detect, investigate and respond to adverse events.

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6. Who rejected the Safer Care Victoria proposals?

Who made the decisions to reject the Safer Care Victoria proposals? Were they ministerial, departmental or Treasury decisions?

They were rejected within the department’s management change process. The department’s outcomes document rejected four of the five as “contrary to the intentions of the management proposal, which is to deliver an operating model within the financial parameters set by government”. The fifth was rejected as fragmenting an integrated function. That points to departmental decisions made within financial limits set by government. I don’t know what ministerial or Treasury involvement there was in individual decisions, other than to say that the most recent restructure was in response to the government-wide Silver review of the VPS (Independent Review of the Victorian Public Service), which had “a focus on entity consolidation and returning the non-frontline public sector towards its pre-pandemic share of employment”.

The implementation of the Silver review appears to risk repeating the problems VAGO found with the COVID Debt Repayment Plan (VAGO, Delivering Savings Under the COVID Debt Repayment Plan, July 2025), namely:

• No definition of “frontline”: the Department of Premier and Cabinet (DPC) and the Department of Treasury and Finance (DTF) didn’t require departments to define frontline workers. Six of seven departments still promised not to cut them.
• Restructures didn’t separate roles: savings came mainly through restructures that didn’t distinguish frontline from back-office roles. Most departments could later show the cuts were back-office, but safety and quality teams are often classed as back office.
• Little tracking: only one department tracked savings against the specific initiatives it planned. The others watched only overall staff numbers and spending.
• No impact assessment: departments weren’t required to assess how savings affected services, so none could show whether services were affected. For the Department of Health specifically, VAGO found the department “did not consider impact assessments necessary”.
• Poor public reporting: the public can’t easily see progress against savings commitments.

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7. Ballpark cost to restore essential capability

What would be the ballpark cost to restore the essential capabilities: hundreds of thousands, millions or tens of millions of dollars?

I can’t provide a formal costing, as only DTF and the department have the information to do that, so my estimate is to show the quantum of costs. The capabilities in question are measured in tens of positions rather than hundreds, so the cost is likely to be in the low millions a year, not tens of millions. For scale, the department’s savings targets are $96.6m and $108.1m (DH response to PAEC 2026–27). The public hospital medical indemnity premium rose 26.4% to $380.9m in 2025–26, an increase of roughly $79m in one year (VMIA). Unsafe care consumes about 12.6% of health spending (OECD). This is why I’ve suggested a review of the long-term outcomes of the Targeting Zero implementation, incorporating later reports such as VAGO’s, to analyse:

• what was implemented from the Targeting Zero recommendations (fully, partially or not);
• the implementation challenges;
• what meaningful safety and quality benefits were achieved, and the costs of each of the actions;
• the current health system, fiscal and societal factors and requirements;

to arrive at the essential (core), important but mitigatable, and ineffective system components, processes and functions required for an effective and cost-efficient Victorian safety and quality system, both centrally and at health service and hospital level.

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8. Three most urgent changes within 12 months

What are the three most urgent changes that would make a measurable difference to patient safety within 12 months?

1. A comprehensive quantitative and qualitative review of the long-term benefits and costs of Targeting Zero, as noted above, including consultation with all health stakeholders, to inform the essential resourcing required for statewide agencies and hospital safety and quality teams to effectively and efficiently detect, investigate and respond to adverse patient events and improve care.
2. Once quantified by the review, commit to the budget necessary to restore essential safety and quality capability at state and health service/hospital level, including data access through the Data Request Hub for health services, the safety agency and researchers, improved surveillance of severe maternal morbidity, and restored obligations for public hospital quality accounts reporting.
3. Return the chief clinical officers to their former roles within Safer Care Victoria, with direct safety oversight.

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9. Can Safer Care Victoria publish independently?

If Safer Care Victoria identifies a serious systemic failure that reflects badly on the Department of Health, can it publish its findings independently, without departmental approval? And can the department prevent or delay publication?

Not currently. Safer Care Victoria is an administrative office of the department and reports directly to the Secretary (SCV Annual Report 2024–25). The Chief Quality and Safety Officer is appointed by the Secretary, and under the Act review reports go to the health service and the Secretary. I’m not aware of any statutory right for Safer Care Victoria to publish findings without departmental approval, or any protection against delay. This is why Targeting Zero recommended an independent body “with its own statutory base” (Targeting Zero), and why question 3.4 asks about statutory independence with the power to publish.

Transparency is the common thread. Whatever the fiscal position, the community is better served when the true state of safety and quality is published.

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