Safety Learning System (SLS) Review Report

The Department for Health and Wellbeing (DHW) commissioned an independent review of SA Health’s Safety Learning System (SLS) following a recommendation made by the State Coroner in his 2019 Findings of Inquest into the deaths of Joanna Pinxteren, Christopher McRae, Bronte Ormond Highman and Carol Anne Bairnsfather.

A comprehensive review was conducted in 2020 by Associate Professor Peter Hibbert, Dr Tim Schultz and Ms Vivienne Leigh.

Response to Report

SA Health’s initial response to the Safety Learning System (SLS) Review Report has been to accept all 31 recommendations made in the Review, establish an oversight group that includes representatives from each Local Health Network as well as SA Ambulance Service to ensure system-wide implementation of all the recommendations from the review.

The proposed implementation plan, a summary of the report and the full report can be found below:


Safety & Quality Unit
Telephone: (08) 8226 6334