A former nurse and hospital executive says he watched safeguards fail his father during a long hospital stay. He argues the problem isn’t what most people assume.
Dale Wakefield knows what a hospital is supposed to look like. He trained as a registered nurse, has run hospitals and large health organisations, and has read the NSW Health policies closely. When his father, who is in his 70s, spent weeks in hospital, he says he noticed what was going wrong.
“Almost every day, nurses would walk in and just dump pills on his bedside table, and he wasn’t in a medical condition where he could actually help himself,” he says.
Some afternoons, he says, he would arrive to find the morning’s tablets still there. More than once, an afternoon nurse told him his father still needed to take them.
“I’m like, well, did you give those to him? She’s like, no, no, the morning nurse would have left it there for him. I’m like, you can’t do that. You don’t know what they are. You don’t know who put them there. You’re putting your registration or licence on the line.”
He says he put the tablets in the bin, then asked whether his father had had his morning medication. The chart said yes.
“I’m like, how can he have had them when they’re sitting on the table and they’re now in the bin?”
Wakefield says he raised it with a unit manager, who he describes as lovely and candid. “Her response was basically, yeah, that’s an issue. It happens a bit, I’ll let the educator know.”
To Wakefield, that response misses the point. “It’s not that they don’t know they shouldn’t be doing it. No one’s accountable for it.”
He says the manager also told him that staff can’t be pulled up on it any more, because the hospital struggles to fill shifts and anyone challenged might stop taking them. “And I’m like, well, that’s a vicious circle, isn’t it? You can’t pull up staff for doing the wrong thing to make them accountable, because they might leave, putting you in a worse position.”
He says he took his photographs of his father’s medication to the hospital’s complaints department. Weeks later he asked whether any incident had been logged on the day he reported it. “The answer was, no.”
There’s little research on this specific practice. The closest is a 2015 study in which researchers observed more than 7,000 doses given at two Sydney teaching hospitals.
Errors occurred in more than a quarter, and none had an incident report. Most were procedural, such as skipped ID checks, and the study did not look at tablets left at the bedside, so it can’t say how common Wakefield’s experience is.
But anecdotally evidence suggests that this is not an isolated experience.
Wakefield also revealed that medication going unadministered and left by his father’s bedside happened constantly throughout his father’s stay, even after bringing the problem to light.
Wakefield doesn’t accept that holding staff to account will drive them away. He thinks it’s backwards.
“I could argue and show a fair bit of research that says, let’s say I went into that hospital to become a manager, and I replaced someone that was like that. And I did it in the right way, and I said, this is the standard that I accept, this is the culture that I’m curating. Here’s how we’re helping people, this is the vision for the ward that I’m managing. I would argue that I would actually attract more people because of that positive culture, quality stance than I would deter.”
In his view, people who care want to work somewhere that cares. “I’d actually have the better people in the hospital saying, I actually want to work with that guy on that ward because of the standards they uphold.”
A ward without standards, he says, goes the other way. “I actually think it creates quite a bit of apathy when you don’t have standards, and then it’s a spiral, really, like a race to the bottom in standards. A self-fulfilling prophecy.”
He remembers a time when the unit manager was someone you were a little afraid of, and says that firmness was part of how he learned. “When you’re dealing with people’s lives, you should be pretty damn firm.”
What he’s calling for, he says, is someone willing to decide what’s acceptable.
“It takes a particularly strong leader of either a unit, a hospital, a ward, to actually put a flag in and say that we’re not gonna stand for that, we’re gonna do this differently.” He puts the cause bluntly: “It’s just weak leadership for accountability.”
Wakefield says the pills were one example. He says his father was repeatedly served food his condition meant he shouldn’t eat, and that a nurse told him she wasn’t responsible for what the kitchen sent. “Of course you are, you work here, sort it out.”
He says physiotherapy kept arriving while his father was away for tests, then not coming back. When he asked someone to coordinate the timing, he says he was told the physios belonged to a different department.
The most serious failures, he says, were in monitoring. His father was admitted unwell with little fluid going in. Wakefield says the doctors’ notes asked for fluid balance monitoring, as NSW Health policy requires. “Days and days in a row, none of it was recorded. Zero, none.” He also says there was a prolonged gap in his father’s intravenous fluids.
He says his father’s observations stayed on the routine schedule despite signs he was getting sicker. “By the time they’d come back for the fourth or sixth hour check, too late, unconscious.” His father became critically ill and needed intensive care. He is now recovering at home, but Wakefield doesn’t expect him to be the same. “He’ll never drive again. He’ll always struggle with his cognitive impacts.”
Wakefield feels that this is a top-down problem. “That’s when an executive says, I’m not responsible either. And then everyone underneath me also believes they’re not responsible. I just look at the top, which is why I escalated the complaint.”
NSW Health’s complaints policy says complaints should be finalised within 35 days, although districts have told a parliamentary committee that complex ones often miss it. Wakefield says his wait has been about three months.
He describes the hospital sending him to the doctor, the doctor sending him back, meetings booked and cancelled, and calls from blocked numbers. “It literally feels like they’re trying not to talk to you about it.” He says the Minister he wrote to replied that the hospital was in “constant communication” with him. “Constant, yeah. The phone rings and then they hang up and it’s a blocked number and they record it as a phone call.”
He says he wasn’t looking for a fight.
“I’m not calling a lawyer. I’m not upset. I just want to know that you’ve heard what I’ve said and that you’re doing something about it. That’s it. When you can tell me that’s on a register somewhere that you’re gonna act on, I’ll walk away and stop bothering you.”
He has since taken the matter to the Health Care Complaints Commission, which received about 10,500 complaints in 2024-25, roughly the same as three years earlier. A 2022 parliamentary inquiry into rural and regional health found a culture of fear around speaking out and a lack of transparency and accountability, though it examined a different part of the system.
Wakefield expects the objection that wards are under-resourced, and says it’s a cover.
“There’s no ratio on earth, even if you had 100 patients to look after, that you would then just dump the pill there and move on to the next one.” A reasonable practitioner, he says, waits with the patient. “If that meant you didn’t get to everybody that day, then that becomes the issue around staffing.” Nurses who blame ratios for poor practice, he adds, “are only shooting themselves in the foot.”
The nurses’ union describes different pressures. It says many wards are overstretched after long-standing shortfalls. Minimum ratios for general wards, one nurse to four patients by day and one to seven overnight, are only now being rolled out, and recruitment is reportedly yet to begin.
Patients are mostly satisfied: in the Bureau of Health Information’s 2025 survey, 92% rated their care as good or very good. A satisfaction survey can’t capture what patients and families never see, such as a tablet signed for and never swallowed.
Wakefield’s father came home changed, and how he got there is hard to hear. How common it is, nobody can say. The things Wakefield describes, observations not recorded, sign-offs that didn’t match reality, an incident never logged, are exactly the things that leave the least trace in the data.
What the available research does show are documented gaps in recording, reporting and escalation in NSW settings. Wakefield’s view is that these are symptoms of a deeper problem. “No-one’s responsible, no-one’s accountable,” he says.
His remedy isn’t punishment for its own sake, it’s a leader who sets a standard, tells good nurses their work matters, and trusts that people want to work somewhere that cares.
Disclosure: Dale Wakefield has an active complaint with the NSW Health Care Complaints Commission about his father’s care, and a separate complaint with the hospital. He is a party to the matter, and the hospital is not named in this article.
