More than 130 Victorian patients have died following major hospital errors in the space of 12 months amid a rise in serious adverse events, with about 80 other patients seriously harmed.
A new government report shows 217 “sentinel events” were recorded in Victorian hospitals in 2024-25, equivalent to about four cases every week and up from 193 the previous year.
Pediatric patients, newborn babies and women receiving maternity care were among the Victorians who were fatally or seriously harmed by healthcare failings.
The 217 incidents included twelve medication errors and major surgical mix-ups where clinicians left an object inside the patient (three cases), operated on the wrong body part (two cases) and conducted the wrong procedure (one case).
In another incident, a patient was either seriously or fatally injured after being restrained, while two Victorians were able to suicide in an acute psychiatric ward.
Only the worst adverse patient safety events, where the error resulted in the patient dying or experiencing serious harm – such as a long-term, serious injury – are categorised as sentinel events.
Hospitals must report sentinel events — and then conduct an internal review to determine what went wrong — to Safer Care Victoria, a health department office.
SCV’s report, outlining the latest data for sentinel events in public (183) and private (34) hospitals, was released on the eve of the Grand Final public holiday.
The annual figures include 27 sentinel events related to maternity and neonatal care and nine sentinel events involving children. Individual hospitals were not named.
The report noted sentinel events, which have been rising since 2020, increased again in 2024-25 but said this was “likely due to several factors” – including work to improve hospital reporting culture.
The report revealed 61 per cent of the 217 recorded sentinel events – either 132 or 133 patients – resulted in the individual’s death.
The remaining patients were seriously harmed including to the point of requiring urgent lifesaving treatment (13 per cent), long-term or permanent injury (12 per cent) and a shorter life-expectancy (6 per cent).
The report identified issues in surgical, pediatric, maternity and mental health care as “key themes” across the sentinel events.
Multiple cases involved a delayed diagnosis, a failure to follow protocols and safety procedures and communication failures leading to crucial information – including scans – being missed in staff handovers.
The report found that, once again, several pediatric cases were linked to a delay in recognising a child had deteriorated despite abnormal observations, changing vitals and parental concern.
In the cases of maternal and neonatal patient harm, key “contributing factors” listed included staff struggling to locate policies and environment factors including “over crowding” and “alarm fatigue”.
The report also revealed that six of the twelve medication errors reported to SCV involved blood thinners, including cases where levels were “too high”, resulting in the patient suffering a haemorrhage. Opioids and other sedatives were linked to five cases, while another incident involved a patient being given a medication they were allergic to.
SCV chief executive Louise McKinlay said in the report’s foreword that “while most care delivered in Victoria leads to positive outcomes, there are times when things go wrong”.
“In those moments, it is essential that we respond with honesty, compassion and a shared commitment to learning,” she said.
She said there had been “continued improvement” in several areas throughout 2024-25 and 99 per cent of hospital panels reviewing sentinel events had included an external expert.
“Insights from sentinel event reviews are vital to improving patient safety and reducing the risk of future harm,” she said.
The reviews included more than 900 recommendations for hospitals to improve patient safety, 42 per cent of which were completed within six months of the reports publication. One in five recommendations related to standardise processes, while 13 per cent called for a new procedure or policy and just under one in ten suggested improved training for staff.
A government spokeswoman said the unexpected death or harm to any patient was a “tragedy” and “our thoughts are with anyone affected”.
“Patient safety is our number one priority,” she said.
“That’s why we established Safer Care Victoria and introduced the Statutory Duty of Candour, strengthening transparency and accountability when serious harm occurs and helping health services learn from these events.
“We have been transparent in the reporting of sentinel events, with the results and improvements we are making released in an annual report each year – this process did not exist before we came to government.”