A warning against Serious Assessment Code Investigations in WA

Serious Assessment Codes (SAC) are internal investigative processes used by hospitals in Western Australia (WA) to review cases where patient harm has occurred.

These investigations are intended to improve care, identify mistakes, and guide staff training and resourcing.

However, the Maternity Consumer Network advises individuals—particularly those from minority communities—to exercise caution and strongly consider avoiding participation in these investigations.

It has become evident that SAC investigations, especially those classified as Level 1 (the most severe), are not consistently being used to improve patient care. Instead, they are often employed to justify unsafe and discriminatory medical practices.

Several concerning patterns have emerged:

Lack of Independence: Some SAC investigations are conducted by clinicians from the same hospital where the incident occurred. This means colleagues are reviewing each other’s actions, leading to biased outcomes and a lack of accountability.

Ignoring Patient Consent: While you can inform the hospital’s patient liaison that you do not consent to a SAC review or forbid the panel from accessing your clinical notes, there is no guarantee they will respect your wishes.

However, you are still entitled to request the investigation's findings and submit a written response to document any inaccuracies.

Government Inaction: The Hon. Libby Mettam raised concerns in 2024 about the misuse of SAC investigations on behalf of affected families, yet there has been little interest or action from the WA Health Minister to address these issues.

The Impact on Ethnic Communities: Systemic racism in WA hospitals has contributed to the preventable deaths of several women and babies. Despite numerous SAC reviews, there has been a failure to make meaningful recommendations to improve care or address health disparities.

WA Health has also appears to have failed to implement Recommendations 19 and 20 from the Australian Commission on Safety and Quality in Health Care’s inquiry into the death of Aishwarya Aswath. These recommendations called for cultural competency training for healthcare staff to improve care for culturally and linguistically diverse (CALD) communities.

Currently, there appears to be no formal policies or training to address systemic racism in healthcare—particularly the dangerous practice of triaging people of colour as low priority in emergency rooms, even when their condition is serious.

This failure has contributed to multiple deaths, including those of Aishwarya Aswath, Supreet Kaur, and Sandipan Dhar.

Protecting Yourself and Seeking Alternatives: Engaging with SAC investigations can be traumatic and ultimately unproductive, as these processes are not designed to ensure justice for affected patients and families nor improve safe medical care.

If you or a loved one experiences harm in a WA hospital, consider these alternatives:

• Seek an independent second medical opinion (note that this may come at a financial cost).

• File a complaint with health regulators such as the Health and Disability Services Complaints Office (HaDSCO) or the Australian Health Practitioner Regulation Agency (AHPRA).

• Consult a lawyer to explore legal options.

• Lobby for change by contacting your state and federal Members of Parliament.

  
  

  People of colour are not obligated to engage with a medical system that repeatedly fails them and causes the preventable deaths of their women and children. Until meaningful reforms are made, prioritizing personal well-being and seeking external avenues for accountability may be the safest course of action.