Women’s and Children’s Hospital staff suspended flights to Melbourne for vulnerable babies because of coronavirus risk

A decision was made within the Women’s and Children’s Hospital to suspend mercy flights for four infants – because of the risk of coronavirus in Melbourne.

Women’s and Children’s Hospital officials ordered the suspension of lifesaving mercy flights to Melbourne implicated in the deaths of four infants in a month who needed heart surgery not available in Adelaide.

After the deaths were revealed by witnesses to a parliamentary inquiry on Tuesday, Victorian Premier Daniel Andrews denied that Melbourne’s Royal Children’s Hospital had no longer accepted transfers due to his state’s COVID lockdown. The Advertiser can now reveal it was a WCH decision based on the risk of coronavirus to vulnerable babies.

Officials have also blamed Victorian advice for the decision not to allow WCH doctors to report their concerns over the deaths in SA Health’s own safety alert system.

The Advertiser can now reveal it was a WCH decision based on the risk of coronavirus to vulnerable babies. Picture: Naomi Jellicoe

The rejection of the doctors’ reports was based on the WCH not having a cardiac surgery unit or a heart-lung bypass life-support service known as ECMO – so there was no unit about which to report a failure.

Doctors were infuriated by the rejection of their reports to SA Health’s Safety Learning System, which meant SA Health Minister Stephen Wade was not immediately alerted to them. The Opposition has labelled the process a “cover-up”.

Clinicians devastated by the deaths have now referred them to the State Coroner, while SafeWork SA is separately considering a union complaint that the WCH contravened health and safety regulations.

After Victorian Premier Daniel Andrews said the choice not to send babies to Melbourne was made “at the other end (in SA)”,SA Health deputy chief public health officer Dr Mike Cusack told The Advertiser he was unsure who cancelled the flights to Melbourne.

However, subsequent inquiries by The Advertiser confirmed the decision was made in SA. Some flights to Sydney continued.

After four deaths in four weeks, Dr Cusack, who is conducting an investigation into the deaths, said he expected his review to take about a month. “To ensure we can perform as detailed an analysis as possible, we are going to ask an external person to undertake part of the review for us,” he said.

“The WCH are of the view they would like a lens placed across it. They are very keen to understand if anything could be done differently and what they could learn from this.”

Early on Thursday, Mr Wade’s office blamed advice given by Melbourne’s Royal Children’s Hospital for barring WCH doctors registering the deaths of the babies needing cardiac surgery or heart-lung bypass on the SA Health safety alert system. “Since 2002, it has not been the practice of clinicians to lodge paediatric cardiac deaths as SLS incidents based on a lack of either of these services,” a spokesman said.

“No SLS reports were made on this basis until earlier this year. Women’s and Children’s Health Network sought an external review by an interstate paediatric intensive care medical expert from the Royal Children’s Hospital, Melbourne, who did not support notification of an incident based on the lack of a paediatric ECMO services.

“All deaths undergo a mortality review.”

In a later statement, SA Health said Dr Cusack’s inquiry would include “whether COVID-19 and related restrictions had any impact upon (the infants’) care”.

“Treatment decisions are always clinically-based and are made by the treating clinicians,” it said.

SA stopped paediatric heart surgery in 2002 because of low case numbers and has since sent children to Melbourne for such surgery.

A business case by WCH clinicians last year argued for its return, citing one avoidable death, but a subsequent independent review rejected the plan.

It argued case numbers would still be too low to ensure a high quality service.

That was because surgeons needed regular cases in order to maintain their skills.

It can also be revealed that a WCH doctor in July tried to report an earlier death under similar circumstances but was told his report was rejected because “there was no evidence of an incident”.

He labelled the involvement of the Melbourne expert a “conflict of interest and the advice sought from the individual was not independent”.

The doctor said there was no review of the system that led to the baby’s death or flaws in the transfer process.

The doctor said: “I felt powerless and helpless, I could not change the system.

“The only system available that records these incidences, I was prohibited from using.”