Andrew Knox’s life changed when he was diagnosed with acute myeloid leukaemia.

But he believes his prognosis would have been very different if he had not been one of the 10 cancer patients in South Australia who received a half dose of chemotherapy a decade ago.

“My life is completely bound up with medical appointments,” Mr Knox said.

“I’ve had 16 significant operations and procedures since the bungle and more to come, I think.

“My wife is currently in Canada to visit our little grandchildren that I will never see except on Facebook or on an iPad.”

Mr Knox relapsed in 2016 following the chemotherapy underdosing bungle.  (Supplied)

The 75-year-old was among the cancer patients given one daily dose of the chemotherapy drug Cytarabine when they should have been given two, at either the Royal Adelaide Hospital (RAH) and Flinders Medical Centre (FMC) over a six-month period in 2014 and 2015.

“The treatment we got was, in fact, worse than getting the correct treatment because by getting it only once a day, it meant that the leukaemic cells were forced into reproduction mode,” Mr Knox said.

“The result of that was that all were doomed to relapse.

“Because I didn’t have any mutations, the evidence was I ought to have been cured.”

The cancer patients given an underdose were treated at the Royal Adelaide Hospital or the Flinders Medical Centre. (ABC News: Che Chorley)

System ‘fraught with danger’

The deaths of four of the relapsed patients – Christopher McRae, Anne Pinxteren, Bronte Higham and Carol Bairnsfather – sparked a coronial inquest.

Just before the inquest began in 2017, Mr Knox underwent a stem cell transplant in order to survive after his cancer returned.

Following two years of evidence, then-deputy state coroner Anthony Schapel found the bungle could have been avoided if there was “uniformity” in the treatment protocols at all SA hospitals.

Mr Schapel also slammed SA Health’s incident reporting system, known as the Safety Learning System (SLS), and recommended it be abandoned.

“In my view the Safety Learning System method of reporting adverse incidents does not work,” he wrote in his published findings.

“Not only that, it does not work across the entire SA Health system.

“The email system of communication between clinicians and other professionals in order to impart information concerning protocol changes and content is fraught with danger.”

Andrew Knox has called for the state government to adopt all recommendations of a coronial inquest into the bungle. (ABC News: Leah MacLennan)

Mr Schapel found the system was initially not used at all following the chemotherapy error at the RAH and later failed to prevent further incidents at the FMC, which resulted in Mr Knox being underdosed.

“The Royal Adelaide Hospital, when they identified it, basically treated it as low-key,” Mr Knox said.

“They issued about 40 emails saying that they were changing the protocol and according to the evidence before the deputy coroner, nobody read those protocols.”

Former deputy state coroner Anthony Schapel recommended the reporting system be abandoned. (ABC News)

Mr Schapel recommended the SLS, which has been in place since 2011, be replaced with a new system that reports adverse events immediately to every hospital’s chief executive and the head of SA Health.

At the time, he said the matter should have been investigated by a royal commission.

Mr Knox has been calling for the state government to adopt Mr Schapel’s recommendations, saying the current system focused on reviewing incidents rather than responding to them.

“The seriousness of the error was compounded by the fact that when it was discovered, there was no plan of action,” he said.

“What should have happened is that we should have been assessed immediately and those who were ready or could, should have gone straight into stem cell transplants.

“When something is ongoing, it’s not stopped by that system at all – it’s a notification system, it’s not a response system.”

Andrew Knox with his wife on their 46th wedding anniversary while he was in hospital undergoing a stem cell transplant.  (Supplied)

Mr Knox said he feared bungles could be repeated if the SLS remained in place.

“It doesn’t only apply to chemo, it applies to everything within the health system,” he said.

“The fact that people are continually affected, hurt and injured after events are known or first reported is just totally unacceptable.

“Errors will happen but there is still no mechanism to deal with them and stop them spreading, and nothing to deal with the care of the patients, which has to be done independently, immediately, not in six months’ time, when eventually somebody gets around to produce a report.”

Doctors ‘disengaged’ with reporting incidents

In 2019, SA Health commissioned an independent review which found the SLS was already “sufficiently flexible” to deliver the changes recommended in the inquest findings.

But that review also found that a “patchiness in the culture of reporting” affected whether incidents would be notified.

It found evidence that clinicians often received a lack of feedback after raising concerns, causing them to become disengaged and frustrated with the system. 

In a statement, SA Health told ABC News that it was preparing a tender process to consider a replacement of the SLS as part of its “ongoing review of IT systems”.

“Since the underdosing incident was identified, there has been continual review and improvement of SLS, including its design and usability, to ensure it is fit for purpose,” a spokesperson said.

“There are clear policies and guidelines supporting safety of patients and management of incidents, which all clinicians are required to adhere to.” 

Andrew Knox (left) and Bronte Higham gave evidence to a parliamentary committee before the inquest. (ABC News: Tom Fedorowytsch)

SA Health said all of the remaining recommendations had been addressed, including the roll-out of a new state-wide IT-based prescribing system which was due to be completed early next year.

“The prescribing system contains the approved SA Health chemotherapy protocols and replaces paper-based processes and records, providing a single view of patients undergoing systemic cancer therapy,” the spokesperson said. 

Doctors not confident in SLS, says union

SA Salaried Medical Officers Association chief industrial officer Bernadette Mulholland said clinicians had a “lack of confidence” in the SLS. 

“The feedback that we get from our membership is they don’t get the solutions that they’re looking for and it becomes a devalued product,” Ms Mulholland said.

Bernadette Mulholland says union members lack confidence in the SLS. (ABC News)

“On the one hand, [clinicians] want to put in SLS notifications, but on the other hand, there’s never any resolution to those SLS notifications, so they start to query what’s the purpose?

“The doctors, the clinicians, need to have confidence in this system that safety issues are raised to the highest level and are resolved at the highest level, so as not to be repeated.”

Ms Mulholland said there should another independent review into the SLS.

Andrew Knox says he will continue to advocate for an improved health system. (ABC News: Brant Cumming)

In the meantime, Mr Knox said he would continue to advocate for an improved health system.

“It’s just crushing,” he said.

“I just don’t understand how you can go to work every day and not fix something as simple as this.

“The only thing that keeps me going is the hope that what I’ve gone through can make it better for other people – and I’m just being ignored.”