Forgotten referral led to patient's death, Victorian shadow minister says

Patient dies after referral 'forgotten' at Mildura hospital, shadow health minister says In short: Victoria's shadow health minister says a Mildura hospital patient whose paper referral was left in a box at the hospital for over a year has died. The patient, who has not been named, is believed to be one of many whose records were "forgotten". What's next? Mildura Base Public Hospital is working with Safer Care Victoria to review what happened. A patient who was not triaged in a "timely manner" at a Victorian hospital that relies on paper records has died, the state's shadow health minister says. It is believed up to 150 patients at Mildura Base Public Hospital (MBPH) were left waiting for care for longer than a year after boxes of paper referrals were "forgotten" about. On Friday Shadow Health Minister Georgie Crozier said she understood that one affected patient had since died. "[These are] patients that have not been triaged, not been diagnosed, not been seen by specialists and haven't had the management and timely care that they deserve," she told ABC Statewide Drive. MBPH discovered the fault through via clinical governance and patient safety processes and reported the cases to Safer Care Victoria (SCV), in line with its obligations. MBPH acting chief executive Matt Jukes declined to comment on the forgotten paper referrals, but said the hospital was "always looking at refining our service delivery and models of care". He said the hospital was working with SCV and the Department of Health "to ensure that if there are any gaps within the services that we provide, that they are identified, they're reviewed". Records still not digitalised In 2023 MBPH and the state government committed to digitising 200,000 patient records over four years, with electronic medical records (EMRs) set to roll out in Mildura, Echuca and Swan Hill at a cost of $14 million. Three years later, Mr Jukes said inpatient records had still not been digitised, and that the hospital needed more funding and time to complete the transition. "From our perspective, we just work within the constraints of what we have available to us,"he said. In a statement, a Victorian government spokesperson said implementing electronic medical records was "a complex, multi-year transformation" and that the Loddon Mallee EMR program was still underway. "The Victorian government is progressively rolling out electronic medical records and CareSync Exchange across Victoria's public health system to reduce reliance on paper-based processes and improve access to patient information," they said. 'Dangerous' system On Friday, a medical student at the hospital told the ABC the paper system was "dangerous" and that patients were not getting the care they needed. "We have a paper-based system, hybrid essentially, where doctors, nurses, allied health all scribble down notes," the medical student said, speaking on condition of anonymity. "We will routinely go on ward rounds and a doctor will run their finger down the length of the paper and say, 'I can't read that. Oh well, next page.' "It is dangerous, I can't believe that in 2026 we have a paper-based system in Mildura." The medical student said they understood why some residents were worried about visiting MBPH. "It's not the staff's fault, [but] if I had something go wrong with me, I'd be jumping in the car and driving to Bendigo," they said. Victoria falling behind on digitalisation In 2024 the state government said the rollout of EMRs in all Victorian hospitals was underway. It is not known how many hospitals are still operating entirely through paper records, but processes differ between them. In regional Victoria, patients such as Horsham woman Penny Flynn have lost confidence in the system after issues with her health information being missed due to the paper system. She has resorted to creating her own folders to manage records and appointments. "It has all my contacts, of all my specialists, all the medications I take and all the people that need to be contacted if I become unwell, and I take that to the specialist with me," Ms Flynn told ABC Victoria Statewide Mornings. Australian Medical Association Victorian president Simon Judkins said paper-based hospitals had always been a problem. "It goes back a long way to individual governance and individual boards and individual health services and so each health service does things their own way," he said. "There's no systemic or system IT response. We're trying to fix that." Dr Judkins theorised that any potential faults at the Mildura Base may have stemmed from a "high turnover of locum staff who aren't familiar with processes". "It's a system that … relies on individuals to be aware of how things work, and when those individuals aren't, things like this get missed,"he said. Calls for 'transparent' investigation Law Partners senior managing solicitor in medical negligence Michael Passaro said the failures reported at MBPH were "deeply disturbing" and called for a 'thorough and transparent' investigation. "An urgent referral is not just paperwork, it represents a patient waiting for potentially life-saving care," he said. "No patient should suffer avoidable harm because their referral was left untriaged in a box." The state government spokesperson said their thoughts were with the loved ones of the patients affected. "When something goes wrong, health services must review what happened, be transparent about the findings and take action to reduce the risk of it happening again," they said. The ABC understands MBPH has reached out to affected patients. [Image text:] MILDURA VALUES