Red flags were being raised for years about systemic failures of process and practice at Bacchus Marsh and Melton Regional Hospital, an Auditor- General’s report has found.
Senior clinicians queried the hospital’s ability to manage its maternity services, while an internal report years before any investigation was launched found the hospital’s obstetric service was an “extreme risk”.
The hospital’s medical services director reported the obstetrics service was “under extreme risk” in 2010 because of a rapidly increasing workload and the expected growth in the health service’s catchment, the report tabled in State Parliament last week reveals.
But the hospital only sought extra funding to manage that growth three years later, in February 2013.
Meanwhile, an unnamed director of obstetrics at a “large metropolitan health service” also raised concerns with the Health Department about the hospital’s maternity services.
The report reveals the obstetrics director claimed the hospital did not have “sufficient medical support or capacity to grow the service”.
In this instance, the hospital advised the Health Department it “had procedures in place with the metropolitan health service to manage higher-risk mothers and infants”.
An investigation commissioned by the department last year found seven of the 11 baby deaths that happened at the hospital in 2013 and 2014 could have been avoided.
It also found that high-risk mothers and at-risk babies were not transferred to larger hospitals.
Demand outstripped capacity
The Auditor-General’s report found many ‘red flags’, including professional competency issues and maternal safety concerns, had been raised by senior medical practitioners.
It also reveals claims that demand for maternity services outstripped the hospital’s clinical capacity were ignored by the Health Department.
The report found “internal communication” problems at the department had “resulted in fragmented responses”.
“There was no central point where these concerns were integrated and collectively assessed,” the report states. “Appropriate and timely action could have averted some of the serious consequences.”
Acting Auditor-General Peter Frost said while hospitals were improving their patient safety culture, there was “still significant work” to do to improve incident management.
“The audit found that there have been systemic failures by DHHS, indicating a lack of effective leadership and oversight, which collectively poses an unacceptably high risk to patient safety,” Dr Frost said.
“Some of these issues were identified over 10 years ago in our 2005 audit.”
