As we reconcile the reports of neonatal murders in Chester, UK, we move quickly to a question of whether similar events could go so unchecked within our own health system. The Lancet responded¹ by recalling reactions to multiple prior health system sentinel events in the United Kingdom and elsewhere, portraying a sequence of interventions that have been inadequate in preventing ongoing incidents. In Lucy Letby's case, administrative systems built over many and extensive reviews and inquiries failed to respond appropriately to repeated early warnings from paediatricians. Measured incorporation of a nimble response to safety concerns from frontline clinicians appears to be missing from UK safety protocols and we should consider whether this is also the case in our health system.

Australia has had analogous sentinel events. Jayant Patel was accused of gross negligence while working at Bundaberg Base Hospital in Queensland, convicted for manslaughter and grievous bodily harm, acquitted on High Court appeal, but then barred from practising medicine in Australia. Three separate high-level inquiries, judicial and non-judicial, broadly focused on practices, systems and processes of Queensland Health.^{2, 3} In July 2023, the Health Care Complaints Commission found Charlie Teo guilty of unsatisfactory professional conduct, for which he was reprimanded with conditions imposed.⁴ Incidents of unregistered practitioners finding employment in our health-care settings continue despite a robust national medical board advancing its own system of checks and balances. The 2018 Royal Commission into Aged Care Quality and Safety made 148 wide-ranging recommendations for the fundamental reform of the aged care system.⁵ This inquiry arose after the admission to hospital of a government-run aged care mental health facility resident who had significant bruising to his hip for which there was no satisfactory explanation, after which the Independent Commissioner Against Corruption⁶ had first concluded damning findings of maladministration.

While these events have been disturbing, Australia has to date been seemingly immune to events as confronting as the Lucy Letby case. There has been a certain confidence that our process of top-down systems review, thorough and often independent, has put in place sufficient safeguards to prevent or at least minimise harm. Yet, the needless deaths of premature neonates, perpetrated from within and against the most vulnerable of human beings, have exposed a security flaw that has been exploited in a devastating manner. Just as cyberthreat protections use increasingly complex security processes, there remain human vulnerabilities both online and in health care, and these are the most difficult to contain. We will never avoid employment of the occasional unscrupulous health worker, but our systems should detect and manage from a very early stage, hopefully before damage is done. For these neonates, committed clinicians finally brought the crisis to consciousness, but the delay was too slow, too late for too many neonates in care. The Lancet calls for a statutory inquiry and no doubt another tranche of recommendations will be forthcoming.

We are all aware that clinical reason can, locally, be subservient to process. Take the recent report of an Independent Governance Review of the South Australian Paediatric Cochlear Implant Program at the Women's and Children's Health Network.⁷ The review addressed concerns around cochlear implant mapping, suggesting ‘that children may have had inadequate hearing for a significant period and that this may have impacted on their development’. The review's lead commented that affected families would have experienced ‘devastation’ and that their experiences ‘have implications for other paediatric Cochlear Implant services across Australia’. An ex gratia payment of $50 000 was offered to families of children identified as being ‘under-mapped’. These findings were widely reported, no doubt adding to distress of affected families and undermining the clinical services of the Health Network itself and especially the involved clinicians. No cochlear implant medical practitioners were included in the review panel. The panel did not examine evidence for actual harm to any affected child, nor did it present a peer-reviewed evidence base for actuality or extent of any developmental delay being associated with cochlear implant under-mapping. Further, it provided no peer-reviewed evidence for an optimal approach to mapping in terms of clinical outcomes. While the review did identify what it felt to be mapping ‘best practice’ and concluded that such practice was not followed, it presented no peer-reviewed evidence to support the implication that practices followed by the Health Network caused adverse outcomes. A further ‘clinical’ review of the service is in progress, though the Governance Review makes no mention of its intention or timetable with details shrouded in secrecy. While the damage done by the existing response has not been lethal, and further light may well be shone by the clinical review, the suggestion that clinical reason in these matters was insufficiently weighted has eery parallels to the Lucy Letby case.

The release of the Cochlear Implant Review without appropriately engaging senior cochlear implant specialist views is, therefore, a triumph of process over clinical judgement. It is a concerning and contemporaneous confirmation that health services in Australia continue to undervalue and undermine clinical inputs into patient safety. Further, it signals that until the dominance of process over clinical outcomes is put back into equilibrium, coal-face clinicians will be limited in their ability to generate needed responses to sentinel events. These are no small matters and our smallest of patients will be safer when the clinician is placed back in the quotidian of patient safety.

当我们核对英国切斯特新生儿谋杀案的报告时，我们很快转向一个问题：类似事件是否会在我们自己的卫生系统内如此不受控制。《柳叶刀》对此做出了回应¹，回顾了此前英国和其他地方卫生系统发生的多起哨兵事件的反应，描述了一系列不足以预防正在发生的事件的干预措施。在露西·莱比的案例中，建立在多次广泛的审查和调查基础上的管理系统未能对儿科医生反复发出的早期警告做出适当的反应。英国的安全协议似乎缺少对一线临床医生的安全问题采取灵活反应的措施，我们应该考虑我们的卫生系统是否也是如此。

澳大利亚也发生过类似的哨兵事件。贾扬特·帕特尔 (Jayant Patel) 在昆士兰州班达伯格基地医院 (Bundaberg Base Hospital) 工作时被指控犯有重大过失，被判过失杀人和严重身体伤害罪，在高等法院上诉后被无罪释放，但随后被禁止在澳大利亚行医。三个独立的司法和非司法高层调查广泛关注昆士兰卫生局的做法、系统和流程。^{2, 3} 2023 年 7 月，医疗保健投诉委员会认定 Charlie Teo 职业行为不佳，并因此受到谴责并附加条件。⁴尽管强大的国家医疗委员会不断推进其自身的制衡体系，但未注册从业人员在我们的医疗机构中找到工作的事件仍在继续。2018 年皇家老年护理质量和安全委员会就老年护理系统的根本性改革提出了 148 项广泛的建议。⁵这项调查是在一名政府经营的老年护理精神卫生机构居民入院后进行的，该居民的臀部严重瘀伤，但没有令人满意的解释，之后廉政专员 6 首次得出了行政管理不善的严厉^结论。 。

尽管这些事件令人不安，但迄今为止，澳大利亚似乎并未受到像露西·莱比案这样严峻的事件的影响。人们有一定的信心，我们自上而下的系统审查过程是彻底且往往是独立的，已经制定了足够的保障措施来防止或至少最大限度地减少伤害。然而，早产儿不必要的死亡是从人类内部针对最脆弱的人群所造成的，暴露了一个被以毁灭性方式利用的安全缺陷。正如网络威胁防护使用日益复杂的安全流程一样，网络和医疗保健领域仍然存在人为漏洞，而这些漏洞是最难遏制的。我们永远不会避免偶尔雇用不道德的卫生工作者，但我们的系统应该从很早的阶段（希望在损害造成之前）进行检测和管理。对于这些新生儿来说，尽职尽责的临床医生最终让他们意识到了危机，但延迟太慢了，对于太多接受护理的新生儿来说已经太晚了。《柳叶刀》呼吁进行法定调查，毫无疑问，另一批建议即将出台。

我们都知道，临床理性在局部可能服从于过程。以妇女和儿童健康网络最近对南澳大利亚儿科人工耳蜗项目的独立治理审查报告为例。⁷该审查解决了对人工耳蜗植入测绘的担忧，表明“儿童可能在很长一段时间内听力不足，这可能会影响他们的发育”。该审查的负责人评论说，受影响的家庭将经历“毁灭”，他们的经历“对澳大利亚各地的其他儿科人工耳蜗服务产生影响”。向被认定为“地图不足”儿童的家庭提供了 50 000 美元的惠给金。这些发现被广泛报道，无疑增加了受影响家庭的痛苦，并损害了健康网络本身的临床服务，尤其是相关临床医生的临床服务。审查小组中没有包括人工耳蜗植入医生。该小组没有审查对任何受影响儿童造成实际伤害的证据，也没有提供经过同行评审的证据基础，以说明与人工耳蜗植入映射不足相关的任何发育迟缓的现实或程度。此外，它没有提供同行评审的证据来说明临床结果映射的最佳方法。虽然审查确实确定了它所认为的“最佳实践”，并得出结论认为这种做法没有得到遵循，但它没有提供同行评审的证据来支持健康网络遵循的做法导致不良后果的暗示。对该服务的进一步“临床”审查正在进行中，但治理审查没有提及其意图或时间表，细节也处于保密状态。虽然现有反应造成的损害并不是致命的，而且临床审查很可能会进一步阐明这一点，但这些问题上的临床原因没有得到充分重视的建议与露西·莱比案有惊人的相似之处。

因此，在没有适当听取高级人工耳蜗专家意见的情况下发布人工耳蜗审查是过程战胜临床判断的胜利。同时令人担忧的是，澳大利亚的卫生服务继续低估并破坏对患者安全的临床投入。此外，它还表明，在过程对临床结果的主导地位恢复平衡之前，采煤工作面临床医生对哨兵事件产生所需反应的能力将受到限制。这些都不是小事，当临床医生回到患者安全的日常生活中时，我们最小的患者也会更安全。