Disciplinary Actions and Preventive Measures Related to Hepatitis C Outbreak at SGH

Mr Leon Perera asked the Minister for Health (a) what are the names of the SGH and Ministry staff who have been disciplined in connection with the Hepatitis C hospital infection cluster in 2015; (b) what are the penalties and/or warnings that they individually received; and (c) for what reasons have these penalties and/or warnings been given in each case.

Miss Cheng Li Hui asked the Minister for Health what are the measures put in place to ensure that the Hepatitis C incident does not happen again.

Madam, our healthcare professionals are committed to doing their best to cure and care for their patients. They have played a critical role in providing good quality healthcare for Singaporeans. Unfortunately, gaps and lapses do happen.

When an outbreak occurs, hospitals must do two things. First is to take steps to stop further transmission and care for the affected patients as best as they can. The second is to review the processes at the individual and system levels and make improvements to reduce the risk of any recurrence.

The Hepatitis C outbreak in the Singapore General Hospital (SGH) is a painful incident – painful to the patients, their families, and our healthcare professionals. The chief executive officer of SGH has apologised for the outbreak. The Ministry of Health (MOH) and SGH are committed to caring for all affected patients by providing them with counselling, support and appropriate Hepatitis C treatment. The well-being of the affected patients and their family members remain our top priority. My Ministry will continue to work with SGH to ensure that they receive the necessary support and care. Once again, let me apologise to the affected patients and their family members for this incident, and especially to those who have lost their loved ones.

To identify the cause of the outbreak and address the gaps, my Ministry has set up the Independent Review Committee (IRC) comprising experienced clinicians from different disciplines, with support from local resource persons and international experts, to determine the cause of the Hepatitis C outbreak and provide an objective and critical review of the response.

After a thorough investigation, the IRC concluded that the outbreak was caused by gaps in infection prevention and control practices at SGH, together with other overlapping factors, such as a change in the wards and greater susceptibility and exposure of the renal patients to intravenous procedures.

As a follow-up to the IRC report, both SGH and my Ministry have taken steps to address the gaps. I will articulate this further later.

MOH and SingHealth also instituted disciplinary procedures to hold our staff to account. We set up independent human resource (HR) panels to examine the roles, responsibilities and actions of key MOH and SGH staff in relation to the incident and to recommend appropriate disciplinary actions.

The SingHealth HR panel submitted its recommendations to the SingHealth Board. The Board decided that the junior and frontline healthcare staff would be required to undergo retraining and competency assessment to improve their infection prevention and control practices. The Board also decided to hold 12 SGH leaders, including senior management, responsible for their failure to enforce a strong infection control regime and incident escalation protocols within the hospital.

The MOH HR panel submitted its recommendations to the Public Service Commission (PSC). The PSC decided to take disciplinary action against four MOH officers holding Director-level or equivalent roles for their failure to intervene early and to ensure that the infectious disease notification and reporting system was effective and rigorous.

The disciplinary sanctions imposed on MOH and SGH staff included warnings, stern warning and financial penalties.

Let me explain. When a warning is issued, it is lodged in the staff's service record. A stern warning is a more serious penalty. Not only is it entered into the staff's service record, it has a negative bearing on his career, including future promotion and awards. A warning or stern warning may be given together with a financial fine.

But, Madam, the greatest penalty is not these disciplinary measures. For everyone involved, including those who had provided direct care to the affected patients, we will carry with us the pain and regret of this incident for a long time to come.

It is, therefore, important for MOH, our healthcare institutions and healthcare workers to learn from what went wrong and make sure the mistake is not repeated. Instead of naming individuals and developing a blame culture in our healthcare institutions, we need to encourage a learning culture to make our hospitals as safe as possible for the patients. This culture of continual learning and improvement is important for enhancing patient safety and the quality of care.

Looking ahead, our focus is to improve our systems and processes to enhance infection control and strengthen detection and response to infectious diseases. Revealing the names of the officers and specific sanctions each individual received does not contribute to better care of our patients. In deciding what to disclose, we have to bear in mind the longer-term impact on our healthcare system and healthcare workers and strike a careful balance.

Let me now turn to the measures that we are putting in place to improve patient safety. Following the IRC's review, SGH has taken steps to improve infection control by enhancing its processes and strengthening cleaning and decontamination. SGH also enhanced its education and retraining programmes for staff and implemented stricter monitoring of infection control practices. To verify that its systems are robust, SGH has engaged consultants from the Joint Commission International, a reputable accreditation and consultancy organisation, to conduct a thorough review and assessment of its clinical processes.

We are also sharing the lessons learnt from this outbreak with all hospitals and working with them to ensure that their infection control, risk management and escalation protocols are in place.

In December 2015, MOH set up a task force headed by Minister of State for Health, Mr Chee Hong Tat, to enhance the national healthcare system's ability to detect and respond to infectious disease outbreaks in hospitals and in the community.

The task force is scheduled to complete its review by the middle of this year. MOH has decided to implement a number of the task force's interim recommendations earlier. This includes setting up a National Outbreak Response Team comprising experts from across the healthcare fraternity. This team will augment the efforts of healthcare institutions to deal with disease outbreaks. Other measures include simplifying processes for notification and reporting of infectious diseases by doctors and laboratories. MOH has also designated the Communicable Diseases Division to assume overall responsibility for overseeing surveillance of all infectious diseases.

Madam, the Hepatitis C incident reminds us of the need to remain vigilant at all times. While it is not possible to completely prevent outbreaks in hospitals, MOH and our healthcare institutions are determined to learn from the mistakes made so that we continue to improve our systems and processes to provide better and safer care to our patients.