‘Substandard’: Shocking report outlines major hospital’s failures

A horror report into Mackay Hospital has been handed down, revealing “system level failures” and at least three children who died as a result of “inadequate” care.

The report into the obstetrics and gynaecology department at Mackay Hospital has been handed down, revealing at least three occasions when inadequate care was a factor in the death of babies, Health Minister Yvette D’Ath has confirmed.

The shocking report, compiled after more than 80 women were interviewed about “substandard clinical care” at the facility, said many women had suffered “long lasting physical and psychological harm” after substandard care at the facility.

Ms D’Ath was visibly emotional when she confirmed there were three cases identified where “inadequate” care led to the loss of a child.

“Those three cases span over 10 years,” she said.

“No family should ever have to experience the devastation of the loss of a child and certainly not under these circumstances.

“To all the women and families who had been impacted by these statements, I offer my sincerest apology.

“Many women describe the experience of being interviewed as part of the investigation as the first time they felt heard.

“What we have seen in this investigation is unacceptable.”

Health Minister Yvette D'Ath speaks after the report was handed down. Picture: Channel 7

A lawyer who is in talks with two women who lost babies at the hospital said that while Ms D’Ath’s apology was welcome, there must be full compensation paid to women and their affected family members who have suffered grievously because of the hospital’s failings.

“Anything less is not good enough,” special counsel Sarah Vallance from Shine Lawyers said.

“The minister’s apology will be welcomed by those who’ve been let down by the hospital’s management and its dysfunctional obstetrics and gynaecology department, but her words must be followed by meaningful action at all levels.

“Patients who were physically and psychologically injured as a result of the hospital’s negligence deserve compensation for medical expenses, loss of income, and pain and suffering,” she said.

“The amount of compensation they receive should not be decided through a mysterious extrajudicial process in which Queensland Health has all the control and bargaining power. For the Mackay community to regain trust in their health service, it’s imperative the compensation pathway is transparent and affords due process to the women involved,” the lawyer said.

Minister D’Ath has given the MHHS Board a week to ‘show cause’ or risk being dismissed entirely.

“Because of the egregious nature of these failings, today I am issuing a show cause notice to the MHHS board as to how they can effectively discharge their duties and obligations and whether any or all of the board members should be dismissed,” she said.

“The board members have until next Friday to respond to this show cause notice.”

Minister D’Ath confirmed four clinicians who worked at Mackay Hospital had been referred to the Health Ombudsman and a fifth has resigned.

“In relation to any findings against individuals I can advise that four clinicians involved in the clinical outcomes outlined in this report have been referred to the Office of the Health Ombudsman by either the investigation team or the clinical review committed,” she said.

“None of these clinicians are now employed by Queensland Health in any capacity.

“A fifth individual referred to in the report has been on leave and I’m advised has submitted their resignation.”

MHHS Interim CEO Paula Foley apologised to families affected by the bungles.

“I would like to deeply and sincerely apologies to the women and their families on behalf of our Hospital and Health Services,” she said.

“Let me be very clear, it is unacceptable that some of these women have received care that is below clinically recommended standards.

“We are in full support of the recommendations that have come through from the investigation.

“We want to ensure we are building our trust and our safety within our community

“As the Minister mentioned, while this investigation was underway we opened a hotline for these women and offered emotional and psychological support to these women.

“These learnings have certainly given us a clear way forward, we have a lot of work to do, we take full responsibility for this.

“I do want to say that we can’t undo the past but we can learn from it. We want every woman’s health journey to be safe and the best that we can do.”

Mackay Base Hospital. Picture: Liam Kidston

Mackay Base Hospital deputy board chair David Aprile apologised for the multiple failures at the hospital and said the board would take “responsibility”.

“No words can adequately say sorry or console people who have gone through the trauma, the pain, the hurt,” he said.

“It is not good enough, and I agree.

“As a board, we must accept responsibility.”

He also defended the hospital staff and said they were committed to making the hospital a “centre of excellence” in the future.

“I’ve spoken with senior staff, their whole attitude is to make this hospital and this HHS a centre of excellence,” he said.

“I say to the community, trust will be built up from the things that happen from here.

“This will become a safe, patient-centred hospital.

“This hospital will become great again.

“The past we can’t do anything about – it is how we control the future.”

He also said he wished he had known “back then what I know now, but for whatever the reason, that was not not the case”.

Mackay Base Hospital deputy board chair David Aprile speaks at the press conference. Picture: Madura McCormack

Ms D’Ath said there were important learnings in the report that should be reflected across Queensland.

“We don’t just owe it to the women of Mackay, but to all Queenslanders who access our health system and our staff that work within,” she said.

The report examined conduct of obstetrics and gynaecology services (O&G) within the MHHS from 1 July 2019 to 1 November 2021, and interviewed 81 women who experienced “substandard clinical care, poor clinical incident monitoring, poor management of safety and quality, complications and clinical deterioration and poor human resource management.”

In one shocking example, the report notes 21 cases of hollow viscus injuries (blunt force injury to the gastrointestinal system) during obstetrics and gynaecology surgery at the hospital in just over a year, where the expected number of cases should be between zero and one.

It was also found the Mackay Base Hospital’s Caesarean Section rate “concerningly” increased from 31 per cent to 43 per cent in 2021.

The report identified a trend of “poor management in obstetrics” including the increase in Caesareans, incorrectly triaged referrals for women with cervical screening abnormalities, “and twin pregnancy and gestational diabetes management practices that were outside recommended guidelines for care.”

The report also notes that various personnel are responsible for the breakdown in care.

“There was limited evidence of engaged respectful communication with women. This was pervasive, and staff across the spectrum of Women’s Health care were identified as contributing to this from time to time,” the report states.

The report found that the ultimate responsibility for oversight of clinical services in O&G at Mackay Hospital rested with various personnel working at Mackay Hospital.

“Those personnel should have been more alert to the complications in O&G care that were happening, should have been integral to the safe management of them and investigated and intervened much earlier than was ultimately done to prevent further harm to women,” the report found.

It was further revealed there was a significant patient safety risk and a “complete breakdown in communication” between senior midwives and consultants, a relationship that should have been managed by the senior leadership team.

“There was very little evidence of interprofessional collaboration, limited evidence of Consultant involvement, and often no recommendations or dissemination of mistakes made and lessons learnt,” the report said.

The report notes the failures at Mackay Base were pervasive and not isolated to any one group.

“When trainee doctors and midwives tried to raise concerns in relation to consultant behaviours, clinical practice and outcomes, their concerns were dismissed by senior staff,” the report states.

Mackay Base’s failure to be re-accredited as a training site also led to degraded care.

When the Royal Australian College of Obstetricians and Gynaecologists declined to re-accredit the hospital as a training site in 2021, two registrars were redeployed to other training sites in mid 2021.

“This has resulted in a junior cohort of principal and resident house officers to provide medical cover for the women’s health service, 24 hours per day, with inconsistent consultant support,” the report states. “This represents a patient safety risk.”

Many of the women interviewed said they held out hope for reform, with a common theme running between them, according to the report.

“We need the hospital(s) to be good, it’s all we have got to care for us,” one person wrote.

The report found that the issues identified spoke to a “problematic workplace culture,” and unless those are identified and fixed, similar problems are likely to occur in future.”

Investigators wrote that they were moved by the “harrowing” experiences of many women, who said they felt they had been ignored, disrespected, neglected, left in pain, and in some cases, discharged back into the care of a GP without a finalised resolution to their problems.

“This was pervasive, and staff across the spectrum of Women’s Health care were identified as contributing to this from time to time,” the report states.

A special advisor will be appointed to the MHHS board immediately to provide independent oversight.

The Mealth Minister has also issued a show cause notice to the board of MHHS as to how they have effectively discharged their responsibilities.

The board members have until next Friday to respond to the notice.

Originally published as ‘Substandard’: Shocking report outlines major hospital’s failures