Premier Jay Weatherill now has no choice but to establish a broad judicial inquiry into SA Health following damning evidence that SA Health blocked important reforms that may have prevented the chemotherapy dosing bungle.
Former CEO of SA Pathology, Ken Barr, claims that for three years attempts by senior SA Pathology staff to implement key changes recommended by the 2012 Brennan/Szer Review were blocked by SA Health because it was industrially and politically risky for the Minister and had no financial benefits for SA Health.
In a recent submission to the Legislative Council’s Select Committee on Chemotherapy Dosing Errors, Mr Barr writes that:
‘implementation of the Brennan review may have enabled the incorrect AML dosage protocol to be discovered and corrected avoiding the dosage errors.’
“Mr Barr’s bombshell revelations include the observation that the Minister for Health Jack Snelling and Chief Executive David Swan have created a ‘fear and blame culture’ in SA Health,” said Shadow Minister for Health Stephen Wade.
“Jack Snelling is directly responsible for the culture that has engulfed SA Health and can no longer hide behind claims he has been misled by rogue operators.”
In 2012, SA Health received the Brennan/Szer report which proposed that clinical haematologists come under hospital governance when undertaking clinical trials.
Mr Barr goes on to note that after the chemotherapy dosing errors were identified “SA Health immediately instructed SA Pathology to urgently implement the Brennan Review recommendations”.
The 2015 independent review of the chemotherapy dosing bungle undertaken by Professor Villis Marshall found that poor governance within SA Pathology and the Royal Adelaide Hospital had contributed to the situation.
As far as the Marshall review panel could establish, the recommendations of Brennan/Szer review had not been progressed. It called for a ‘rectification plan’ referencing the 2012 report.
The 2012 recommendations were reiterated by a second external report in 2014 by Ernst and Young. 
Three years after SA Health received a report calling for change, another review found that poor governance which should have been addressed contributed to the adverse outcome.
“David Swan says that Ken Barr should be held responsible because he was at the helm of SA Pathology for three scandals. On the same logic, Minister Snelling and Mr Swan should he held responsible for management failures in SA Health under their watch” said Stephen Wade.
“Premier Weatherill must accept that the only option now is to establish a judicial inquiry into SA Health”.
 “Governance of Clinical Services Conducted by SA Pathology Clinical Staff: A Review.” Peter Brennan, Jeff Szer, June 2012
 http://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/About+us/Reviews+and+consultation/Independent+review+of+incorrect+dosing+of+Cytarabine/, Para 106.