Category: business

Management failures and a rape of a five-month-old baby

Earlier this year, SafetyAtWorkBlog reported on the attack on a nurse in the Torres Strait Islands north of Australia, the investigation of the issue by Queensland Health and the mechanisms introduced to get the working conditions and accommodation up to a safe level.  In this case there was a clear link between occupational health and safety and the security of a worker.

OHS law in Australia obliges workers and those in control of a workplace to ensure the safety of people on their premises.  Last week the Northern Territory government received a report (081128vol1-f9c6d46d-75d5-4a5e-95e7-7c040ae6600c1) into the security measures at the Royal Darwin Hospital.  This hospital has undertaken fantastic medical work in the past, most noticeably, on a large scale following the bombings in Bali in October 2002.

However it failed to prevent the rape of a five month old female infant on 30th March 2006, while the indigenous baby was an inpatient.

Carolyn Richards, the Health & Community Services Complaints Commissioner, said in her report

As a result of a complaint reported to the Health & Community Services Complaints Commission an investigation was undertaken by the Director of Investigations, Mrs Julie Carlsen, who is employed as the Director of Investigations (DI) Health &  Community Services Complaints Commission.

This report highlights that the Department of Health & Community Services (DHCS) needs to implement effective risk control mechanisms to minimise the risk of an assault on a vulnerable inpatient in the Royal Darwin Hospital (RDH). The investigation has led to the conclusion that DHCS (DHF) and RDH have not complied with the applicable Australian Standard. It has also revealed that crucial information has been withheld from an expert engaged by RDH to review security arrangements and from the DHCS (DHF) Security Manager based at RDH. This report also details inadequacies and failings by those responsible for managing RDH who have failed for over two years to implement and maintain better security for patients in the Paediatric Ward. It is published with the hope that it will cause DHCS (DHF) and RDH to give higher priority to improving its risk management and security procedures.

The Commissioner’s conclusions are worth including here so that OHS professionals and security officers can establish appropriate procedures for their workplaces.pages-from-081128vol1-f9c6d46d-75d5-4a5e-95e7-7c040ae6600c1

1. On 30th March 2006:

  • There were no arrangements in place on the Paediatric Ward to ensure the safety and inviolability of vulnerable patients.
  • No risk assessment had been conducted.
  • The arrangements in place did not comply in any aspect with the Australian Standard which sets the benchmark for proper security.
  • There was no control on access to the Ward or to the patients.
  • The staff had not received adequate training, and possibly none at all, about the risks arising from lack of security arrangements.
  • In 2002 RDH had commissioned and received an expert consultant’s assessment and report on security arrangements at RDH. The Terms of Reference did not require 5B to be assessed. By 30 March 2006 the recommendations in the report had not been implemented in Ward 5B. This failure can only be described as shameful.
  • Following the rape of the infant police were not notified for about 2 hours.

2. Action taken by RDH after the rape to improve security was: (a) slow (b) inadequate, and (c) has not been adequately evaluated or reviewed to determine its effectiveness

3. RDH has a Security Manager on site as well as an NT Police member stationed at the hospital. Neither has been asked to evaluate the security on the Paediatric Ward either before or after the rape of the infant.

4. Staff working on the Paediatric Ward have not been trained at their induction on the elements of security arrangements to reduce the risk to vulnerable patients nor has there been adequate ongoing training of staff before or after the 30th March 2006 incident.

5. In 2007 the same expert safety and security consultant, as in 2002, was engaged to assess security arrangements at RDH. He was not informed of the rape of the infant in March 2006 nor was he asked to report specifically on arrangements in the Paediatric Ward.

6. On 21 November 2007 two investigation officers from the Health and Community Services Complaints Commission visited the Paediatric Ward by prior arrangement. They were able to enter the Ward and wander around, have entry to every part of it and stand at the nurse’s station, for about 25 minutes without anyone asking who they were and why they were there.

7. Management’s lack of commitment to the proactive identification of risks and to taking appropriate action has not created a culture where each member of staff takes responsibility for identifying and reporting risks and developing safe practices.

8. A security review of RDH was carried out by an expert hospital safety and security consultant who issued a report in 2007. The Security Manager of DHCS (DHF) was not given a copy even though he requested it. HCSCC enquired of RDH management why he was not given a copy and RDH have offered no explanation. On 31 October after this report was published to RDH and DHF the CEO of DHF advised this Commission that he had finally been given a copy and that he had seen a draft copy.

9. RDH Maternal and Child Health Clinical Risk Management Committee considered security in the Paediatric Ward following the incident. The Committee met on 16th May 2006, 2.5 months after the rape of the infant. It met a further 4 times. It submitted an action plan to the General Manager of RDH in July 2006. At its last recorded meeting on 5 September 2006 there had been no response from the General Manager on the recommendations, particularly with respect to installing CCTV cameras with recording facilities on the Paediatric Ward. There were still no recording cameras on the Paediatric Ward as at June 2008 although a CCTV system had been installed in the kitchen area to deter the pilfering of food. Dr David Ashbridge on 31 October 2008 advised, when responding to a draft of this report, that CCTV cameras were installed in Paediatrics on 25 August 2008.

10. The surveyors from the Australian Council of Health Standards which accredits RDH probably did not receive all relevant information about the incident of 30 March 2006 and what action RDH were taking. Those surveyors on 13 October 2006 were informed by RDH that the patient information pamphlet and admission interview are being reworded to reflect the changes to ward access. There was no verification throughout the investigation that any action had been taken by RDH to implement the recommendations of the review. Neither the report of ACHS nor records of information given to ACHS have been provided to the HCSCC. DHCS (DHF) was invited to provide me with those relevant documents in response to this draft. No response was received on this issue from DHF or RDH. According to the published information of ACHS the accreditation survey commences with a self assessment by the hospital concerned. This Commission specifically requested details and copies of the information provided to the ACHS surveyors but no response was received from either the CEO of the Department or the General Manager of RDH.

11. The governance arrangements at RDH do not promote adequate transparent accountability of the General Manager and the Department of Health and Families for the operation of the hospital. Control of all aspects of the day to day management of RDH rests in the hands of three individuals. This includes staff recruiting, training, security, nursing and medical services, procurement, record keeping, financial accountability and risk management. Such specialist management groups as exist are subordinate to the General Manager’s authority. The General Manager reports to the Director of Acute Services who reports to the CEO of the Department. I have been unable to find out what role the Royal Darwin Hospital Board has since its last annual report to 30 June 2006. 

It is well worth obtaining the complete report to understand how such an individual tragedy occurred.  As one media commentator has posited

“One wonders what the reaction would have been if a non-indigenous infant was raped.”

Fair Work and OHS

Last week the Deputy Prime Minister and Minister for Workplace Relations, Julia Gillard, delivered on some of the government’s promises by presenting the Fair Work Australia Bill into the Australian Parliament.  This does not present a revolution but is a solid rollback of some of the excesses of the previous (conservative) government.  The responses from employer groups and trade unions were in the tones and on the topics that were expected.

The National Review into Model OHS Laws rolls on towards its January 2009 deadline.  The OHS law review was not something urgent for the government, even though it was an election pledge, and it does not indicate a commitment by the government to improving the level of safety in Australia.  The aim is to provide an easier way of managing safety across state borders in Australia with the hope that this will flow to benefit the safety of workers.

It is important to remember that this review came after years of concern about the perception(?) that OHS was part of the red tape of managing businesses, and therefore an unacceptable cost burden.  The danger in this review is that the recommendations will reduce the business costs with no discernible improvement in safety.

There are many OHS professionals and organisations who are hoping for some grand review of workplace safety.  It is a review of law and business bureaucracy, not safety.  Those who will most benefit will be large companies that operate in multiple States.  It will provide no change to small business.  It will not increase safety in the vast majority of workplaces.  It may improve the bottom line company results in 2009 when profit growth is declining but that just means that managerial bonuses are less than normal.  It does not mean that the cost savings will be used to improve safety.

The Fair Work Australia Bill and the National OHS Law Review may change some of the ways in which corporates approach OHS but they will have little, if any, benefit to individual workers.

It is important to remember that any legal changes always benefit legal practitioners, as well.  And OHS lawyers are almost always there after the incident in order to minimise company damage.  Policies and procedures are largely determined without legal involvement.  Machine guarding is not installed by lawyers.  Abusive supervisors are not tempered by legal threats.  Safety is the manager’s job in partnership with the employees, and it will always be so.

Safe Driving and OHS management impacts

SafetyAtWorkBlog has always been critical of those OHS professionals who try to explain OHS in comparison with driving.  They are different processes in different environments with different purposes and different rules.

However, there is a section of overlap and this relates to those whose work environment is transport and driving.

Worksafe Victoria has released a “Guide to safe work-related driving“.  This is essential reading for fleet managers, in particular, but good fleet managers would already have OHS as part of their driving policies.

For those of us who have not known how to interpret OHS obligations for our company vehicles, WorkSafe has issued these clarifications:

  • purchasing and maintaining a safe and roadworthy feet
  • ensuring employees have the relevant appropriate driver licences
  • scheduling work to account for speed limits and managing fatigue
  • providing appropriate information and training on work related driving safety
  • monitoring and supervision of the work related driving safety program.

In this type of workplace, workers seem to have as many obligations as employers but WorkSafe has listed for following as employee duties:

  • holding a current, valid drivers licence
  • abiding by all road rules (eg speed limits)
  • refraining from driving if impaired by tiredness or medication
  • reporting any incidents required by the employer’s program
  • carrying out any routine vehicle checks required by the employer.

There are many areas of contemporary life where the OHS obligations can seem absurd but work-related driving has always been a neglected area of workplace safety.  Every time SafetyAtWorkBlog receives notification of traffic incidents, the emergency services are asked whether the vehicle was being used for work purposes.  Unless it is a bus or a chemical tanker, the question is rarely asked or the information recorded at the scene of the crash.  As a result, the data on work-related driving incidents is scant and WorkSafe has done well in applying what there is.

The guide is terrific but it won’t raise the awareness of these necessary business and employee obligations until WorkSafe’s enforcement and investigative resources are included in traffic incidents and until a case law of OHS prosecutions for work-related driving is established.

The practice of having police and criminal prosecutions replacing OHS prosecutions for work-related incidents must end.  A transport vehicle is a mobile workplace and should be treated as such by having prosecutions under the road transport legislation AND OHS laws.  If not, we will be getting more airbags and less hazard elimination.

Sexual harassment and occupational health and safety

Some old-time safety professionals are struggling with the inclusion of psychosocial hazards in their safety management programs.  Some deny the relevance of sexual harassment to their duties and hope that the issue can be contained within the human resources department, the “dark arts” of workplace safety. 

Many of these same safety professionals are calling for more evidence-based decisions on workplace safety.

Evidence is now in on the social and work impact of sexual harassment. Australia’s Human Rights Commission has issued Effectively preventing and responding to sexual harassment: A Code of Practice for employers‘  which states on page 48

Employers have a common law duty to take reasonable care for the health and safety of their employees. This common law duty is reinforced by occupational health and safety legislation in all Australian jurisdictions.

An employer can be liable for foreseeable injuries which could have been prevented by taking the necessary precautions. As there is considerable evidence documenting the extent and effects of sexual harassment in the workplace, it has been argued that the duty to take reasonable care imposes a positive obligation on employers to reduce the risk of it occurring.

A work environment in which an employee is subject to unwanted sexual advances, unwelcome requests for sexual favours, other unwelcome conduct of a sexual nature, or forms of sex-based harassment, is not one in which an employer has taken reasonable care for the health and safety of its employees. A work environment or a system of work that gives rise to this type of conduct is not a healthy and safe work environment or system of work. An employer could be regarded as not having acted reasonably to prevent a foreseeable risk if practicable precautions are not taken to eliminate or minimize sexual harassment in the workplace.

Failure to fulfil the duty of care can amount to a breach of the employment contract as well as negligence on the part of the employer. This means that an employee who has been harmed could bring an action against their employer in contract or tort.

The guide can do with considerable translation to what businesses see as useful codes of practice in the application of safety management but perhaps that is for the private sector and State OHS regulators to work on.

There seems to be enough information available now on sexual harassment, fatigue, bullying, violence, fitness for work, shift work, depression and other matters, that the safety profession should be more embracing of these concepts in their own planning.  Let’s hope that in this discipline we do not have to wait for generational change to achieve a change in approach.

sexual-harassment-cop2008-cover

Mining fatalities and accountability

The 11 November 2008 edition of The Australian includes a page 2 story where the previous manager of the Beaconsfield Mine has been called on to be held responsible for the management failures that led to the death of Larry Knight in 2006.  The call was made by counsel for Larry Knight’s family and the Australian Workers’ Union in a submission to the Tasmanian inquest into the fatality.

According to the media report, the wrong decision was made in trying to stabilise the working area of the mine and that the risk assessment process was inadequate.  The latter comment should be of considerable interest to OHS regulators and safety professionals.

The importance of the Tasmanian Coroner’s findings are illustrated by comments in the submission by the counsel for the mine.  The media report says that 

“…Dr Neal tells the Coroner the mine had done all it reasonably could to guard against the risk of rockfall and to manage the mine’s notorious seismicity.” [emphasis added]

This is particularly important when considering the introduction of “reasonably practicable” into the OHS legislation throughout the Australian States being considered by the National OHS Law Review.

It is regrettable that the to-ing and fro-ing in the inquest is not getting as much media attention in the non-mining states, as there have been many risk management and accountability issues raised.  The media is likely to wait until the findings of the Coroner, Rod Chandler, and focus on the result rather than the journey.

There was a similar experience in New South Wales with the inquiry that followed the drowning of four mine workers at the Gretley mine in November 1996.  The information did not resonate to the rest of Australia except through the mining sector, yet there were important lessons from the inquiry.  Most OHS professionals, if at all, would recollect the prosecution of Gretley mine managers on matters of culpability, rather than the death of the four workers.

When the Tasmanian Coroner hands down his findings in the near future, it will be very useful to consider them in the light of the earlier reports, assessments and papers, among many others, listed below. 

SafetyAtWorkBlog is a strong advocate of learning new OHS management practices by looking beyond one’s field of expertise.  OHS professionals, safety managers and risk managers need to watch the action in Tasmania and other jurisdictions for themselves and not rely on a small group of OHS lawyers to bring matters to their attention and advise them how to avoid their responsibilities.  Accountability is a moral and legal responsibility.

Holding Corporate Leaders Responsible by Andrew Hopkins

The Impact of the Gretley Prosecutions by Andrew Hopkins

Mine Safety – Law, Regulation, Policy by Neil Gunningham

A submission by the Tasmanian Minerals Council on CRIMINAL LIABILITY OF ORGANISATIONS – ISSUES PAPER NO 9, JUNE 2005 to the Tasmanian Law Reform Institute

N Gunningham, ‘Prosecution for OHS offences: deterrent or disincentive?’ (2007) Sydney Law Review, 29 (3), pp 359-390.

R Guthrie and E Waldeck, ‘The liability of corporations, company directors and officers for OSH breaches: a review of the Australian landscape’ (2008) Policy and Practice in Health and Safety 6(1),
pp 31-54. 

N Foster, ‘Mining, maps and mindfulness: the Gretley appeal to the Full Bench of the Industrial Court of NSW’ (2008) Journal of Occupational Health and Safety – Australia and New Zealand 24(2),
pp 113-129.

Statements on Australia’s OHS review report

According to today’s The Australian, Australian trade unions has “panned” the first report by the National OHS Law Review.  Here is what the ACTU Assistant Secretary Geoff Fary said,

Geoff Fary
Geoff Fary

 

“We are pleased that the Panel Report has recognised that breaches of OH&S laws are criminal rather than civil matters. These recommendations are a step in the right direction, but need to go much further to protect working people by tightening up the rules on employers’ duty of care to their workforce.

“There is a real need to address the carnage that is taking place in workplaces by increasing fines and tightening up employers’ duty of care, but we are concerned that in NSW and QLD injured workers and their families will lose out because they already have laws that squarely put the onus of proof on employers when they allegedly breach the law.”

“Unions believe that the ability to fine companies a percentage of the turnover would be a better deterrent, because even a $3 million fine is a drop in the ocean for some big corporations. At the moment employers can get fined more for breaching trade practices law than for being found guilty of contributing to employees being killed or maimed in their workplace.

“The courts should also be encouraged to use the maximum penalties. At the moment they don’t.

“Unions will continue to campaign for laws that put an unqualified duty of care on employers to provide a healthy and safe workplace.”

For balance, below are the relevant statements from Mr Scott Barklamb, Director of Workplace Policy
with the Australian Chamber of Commerce & Industry:

“Whilst there is significant detail to be analysed across the report’s 75 separate recommendations, the review panel appears to have taken a sound approach on critical issues such as ensuring that the core safety obligation on employers is limited to doing that which is reasonably practicable, and that the prosecutor must bear the onus of proving any breach of OHS law beyond reasonable doubt.”

Michael Tooma, a partner with Australian law firm Deacons, was commenting on a survey that his firm undertook which indicated that the respondents would prefer a “clean sheet” approach to OHS regulations in this country rather than trying to reconcile laws from nine jurisdictions.  

At this point in the review process, any change in direction is highly unlikely and may not fit with the Review Panel’s terms of reference.  The risk in doubts about the process is that an unstable OHS legislative structure could be imposed on Australia that nobody will be happy with and, of course, longevity and continuing relevance is an important consideration in legislative development.

The cautious comments by Scott Barklamb are wise in that the really contentious elements of reform are due in the second report on broader OHS matters due in early 2008.

Safety professionals should be the “child in the crowd”

One of Hans Christian Anderson’s most popular tales is The Emperor’s New Clothes.  For those unfamiliar with the story an English translation is available.

But in summary, an emperor hires two swindlers to make him the finest clothes.  The swindlers pretend to create a gown from the best material and tell their client that it happens to be invisible to fools.  The emperor parades through the town in his new outfit an a young child yells out that the emperor is, in fact, naked.  The townsfolk see through the swindle.

It is the job of OHS professionals and advisors to be the ones to point out the obvious to business or to burst the preconceptions that are hampering safety improvements.  Interestingly, there are no repercussions for the child in the tale and, once shown the fallacy of his beliefs, the emperor continues with the parade.

It is also worth bearing the many lessons of the Emperor’s New Clothes in relation to the purchase of personal protective equipment, project briefs, verification of qualifications and the sycophancy of colleagues.

It is helpful to think that once back at the palace, he revoked the contract with the swindling tailors but that is outside the original tale.

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