There have been several media reports of the disappointment in the findings felt by Larry Knight’s family but little else in the media, particularly over the weekend when some retrospection could have been expected.
However, the Tasmanian workplace relations minister, Lisa Singh, issued a statement last week. The most significant parts of the statement are
“I was pleased that the coroner Mr Rod Chandler noted in his report that the inspectorate was adequately staffed,” Ms Singh said. “I accept his criticism that at the time of the rock fall that killed Mr Knight, Workplace Standards was not sufficiently resourced to handle some issues of mine safety. That has now been rectified.
“I am seeking further advice on his recommendation that an audit of the office be undertaken each year to ensure that it is properly fulfilling its statutory duties.”
“Maurice Blackburn Special counsel Kamal Farouque, who acted as Counsel for the Knight family and the AWU throughout the Coronial Inquest, said that Coroner Rod Chandler’s findings include several major criticisms including:
ground support at the mine was inadequate;
the mine failed to put in place a comprehensive, rigorous and properly documented risk assessment process; and
if a thorough and systematic risk assessment process had been conducted, the likelihood of Mr Knight’s death occurring would have been reduced, perhaps significantly.
“What is plain is that the Coroner has made findings that indicate safety deficiencies,” Mr. Farouque said.
“A lesson to be learned from Mr Knight’s tragic death is the critical importance of proper risk management practices to worker safety, particularly in the mining industry,” Mr. Chandler found.”
Ethics is gaining an increased level of attention in the safety profession in Australia but remains way behind other professions and the business community in general.
The UK’s Ethical Corporation Institute has made available a “pubcast” with one of the authors of a report entitled “Best Practices for Designing Effective Ethics Programmes”. The report itself is only for sale so I recommend you gain as much information from the podcast as possible or request a summary.
Interestingly a world-class ethics expert has returned recently to Australia after many years on the international stage. Howard Whitton will be conducting a workshop in Melbourne on 30 March 2009 concerning “Managing Ethics and Values: Beyond the Code of Conduct”. Below is an article I wrote about a seminar I attended early in 2008
Howard Whitton is one of those Australians who are obscure but when brought to one’s attention you feel guilty that you did not know of him. I first heard Howard speak at an ethics seminar in Melbourne in early 2008.
I attended from curiosity because the safety profession, by and large, in Australia has paid lip-service to professional ethics, and still does. I attended an Ergonomics Society conference almost ten years ago in Sydney where one of the speakers, a member of the society, spoke about professional ethics. Apparently that it was the first time that the Ergonomics conference had ever “discussed” ethics.
Other organizations profess to have an ethics procedure but this is shrouded in secrecy making it difficult for members to know the ethical parameters of a profession. Professional ethics come from open and active discussion of issues such as conflict of interest, confidentiality, whistleblowing, rather than developing a few sheets on professional conduct and thinking the process has ended.
Howard’s presentation in Melbourne surprised. It was in plain English, and overwhelmingly relevant. Howard had a professional film scenario that he based his presentation on. The film involved all the elements of a road construction program from political pressure, safety compliance, environmental considerations, resource allocation, and personal choice. It showed the decision-making processes that safety professional frequently face themselves or have an active role in. It was a microcosm of the project manager’s contemporary role.
The moments I remember are when bones are discovered in the construction project. This echoed the need to manage a project in sensitive environmental areas. One of the workers takes photos of each stage of the project as a hobby, without realizing the photos could be evidence. The project manager is already working within the project parameters when a political (undocumented) element appears that substantially affects the project.
I had half-expected a dry academic discussion and ended up in a fascinating safety-themed debate. If there was one SIA seminar that I would attend this year it would be one of Howard’s workshops being held in late-March in Melbourne, prior to the Safety In Action Conference.
For those members who, like me, weren’t aware of Howard Whitton, I would strongly recommend you look at the online resources listed below.
According to the Ethicos website:
“Following a career as a public servant in Australia, Howard has worked since 1999 in 11 countries as a specialist consultant on Public Sector Ethics, Conflict of Interest, Whistleblower Protection, institutional integrity systems, ethics codes, disciplinary investigations, and training/capacity-building in ‘Ethical Competence’, both for public services and international organisations. After completing a three-year term at the OECD’s Public Governance and Territorial Development Directorate in Paris, Howard was asked to serve as one of two independent specialists helping to establish the new Ethics Office for the UN Secretariat. Since 2006 Howard has been Team Leader on various Ethics/Integrity/Anti-corruption capacity-building projects for national governments, UN specialist agencies, and international NGOs.”
Lucky for us Howard is spending some time at home in Queensland.
In 19 December 2008 Melody had an article printed in Asia Times Online concerning the social impacts of a proposed mine on the small Indonesian island of Lembata. In this era of corporate social responsibility, safety professionals have a broad brief which covers many industrial, corporate and environmental responsibilities and it is often company behaviour in far-flung outposts of the corporate structure or the world that indicates a clearer picture of corporate and safety culture.
Melody’s article is highly recommended for those with a social conscience, for those in the mining sectors and for those whose companies have Asian operations.
In 2003, Melody wrote an article on the health risks of the use of depleted uranium for Safety At Work magazine (pictured below). That article can be accessed HERE.
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.
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.
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.”