Review finds deaths of seven babies due to ‘key failings’ at Melbourne hospital

Victoria’s health minister Jill Hennessy says families deserve to know truth about ‘shocking failure’ at Djerriwarrh health services in Bacchus Marsh and Melton

Victorian health minister Jill Hennessy says Djerriwarrh health services ‘failed to adjust or update its practices in recent years’. Photograph: Julian Smith/AAP

A series of “key failings” in a Melbourne hospital led to the deaths of seven babies, a review has found.

The board of the Djerriwarrh health services in Bacchus Marsh and Melton has been sacked after the review found a higher than normal number of babies dying.

Victoria’s health minister, Jill Hennessy, said on Friday the deaths of 10 babies in 2013 and 2014 were being investigated, with a review finding seven could have been avoided.

She said the investigation would be transparent because the families deserved to know the truth about the “shocking failure”.

“They absolutely have a right to know what happened and what is happening at their local health service,” Hennessy said.

The review found “a series of failures and a number of deficiencies in the care provided”.

“It is now evident that Djerriwarrh failed to adjust or update its practices in recent years, to respond to rapid population growth in the region,” Hennessy said.

“The number of births per year increased quickly and a number of cases, which were not necessarily low risk, were being accepted when they should have been referred to another health service.”

Senior staff from the Royal women’s hospital have been seconded to Djerriwarrh to provide expert oversight and better clinical training for staff. The affected families may be eligible for compensation.

“I am deeply conscious that nothing can change the past for these families,” Hennessey said. “Every check and balance that should have been in place at this health service failed.”

A senior doctor, who was close to retirement, has left and a new director of obstetrics and gynaecology has been appointed.

Director of obstetrics and gynaecology, Surinder Parhar, retired from Djerriwarrh health services in July. He had been at the hospital for 30 years.

A health service the size of Djerriwarrh could expect to have about three to four stillborn or newborn deaths per year.

Dr John Ballard, who was appointed to the Djerriwarrh board to investigate the deaths, said they resulted from “multi-system failure” and there was not one doctor common to each case.

The Victorian secretary of the Australian Nursing and Midwifery Federation, Lisa Fitzpatrick, said concerns about a lack of staff, policies and equipment at Djerriwarrh’s maternity services were raised with the health department in 2014.

“Some midwives, and possibly doctors, had raised concerns with management and left the service in frustration when their concerns weren’t addressed,” Fitzpatrick said.

“We know that there were an increased number of births at the service and this was not proportionately matched by increased staff or infrastructure.”

The Australian Health Practitioner Regulation Agency (AHPRA) apologised on Friday for the length of the investigation into a long-serving doctor at the health service, who had first been complained about in 2013 because of concerns about his care of a mother after the stillbirth of her baby.

“AHPRA acknowledges that it took longer than it should have to investigate that complaint, which related to a single case and the follow-up care provided to a mother after birth,” the regulator said in a statement.

The medical board only imposed conditions on the doctor’s registration in June this year, and while it meant he required further education and monitoring, he was still allowed to practice.

However APHRA said the medical board was never advised of abnormally high perinatal mortality rates at the health service, or about any concerns about that doctor’s care of other patients.

It meant the medical board did not refer the doctor to a medical tribunal, who would have had the powers to deregister the doctor, because the available evidence about his follow-up care of the mother did not meet the threshold for tribunal referral.

AHPRA CEO, Martin Fletcher, apologised for the time taken to investigate the complaint about the doctor.

“Avoidable delays in the management of notifications are not acceptable,” he said.

“We have rectified the identified shortcomings in our processes and will keep these under close review.

The doctor surrendered his medical registration of his own accord on 1 October. He is now no longer able to practise medicine.

Law firm Maurice Blackburn said it had received inquiries from a number of families over the deaths, as well as from mothers who had suffered other complications during labour and birth that had left their babies with long-term injuries.

Principal and medical expert at the firm, Dimitra Dubrow, said families had a right to know “why the system has failed them so catastrophically”.

“To find out that a death of a baby was preventable is particularly devastating,” she said. “The issues are clearly diverse but in the case of one of the families who have contacted us, the complicated nature of the labour should have prompted a transfer to another hospital,” Dubrow said.

“In addition to approaches about the deaths, we have been investigating another case for some time and the firm will be issuing Supreme Court proceedings against Bacchus Marsh and Melton Hospital [Djerriwarrh Health Services] on behalf of a severely disabled baby who suffered a hypoxic brain injury at birth.

“This baby was born in early 2013.”

Alarm bells should have rung for the hospital and authorities long ago, she said.