Official review of Port Pirie Hospital handed down after ‘dead baby in bucket’ investigation

A catalogue of errors at one of the state’s flagship regional medical facilities has been laid bare, following a four-month inquiry.

SA Health chief executive Dr Robyn Lawrence, pictured in her office on Monday, March, said the community could be confident in Port Pirie Hospital’s care. Picture Dean Martin

Foetuses and dead babies must be treated with the “same respect, rigour and attention” as other bodies, according to an official review of an embattled regional hospital that failed to spark disciplinary action.

SA Health investigated Port Pirie Hospital after whistleblowers revealed a dead baby mix-up, and an aged care resident being “liquefied” in late 2021.

The four-month inquiry’s findings, published today after The Advertiser’s revelations, laid bare a catalogue of errors at one of the state’s flagship regional medical facilities.

The Mid North hospital will be forced to overhaul its mortuary rules but no staff will be reprimanded, despite the review concluding operational blunders failed families.

While no employees will be disciplined – which whistleblowers are outraged at – the Yorke and Northern Local Health Network again apologised and accepts the review’s 13 recommendations.

Port Pirie Hospital was investigated by SA Health after whistleblowers revealed a dead baby mix-up, and an aged care resident being “vaporising” for weeks in late 2021. Picture Dean Martin

Findings include finalising new mortuary guidelines with appropriate contingency plans, mandatory “robust” identification checks requiring double signatures, proper records, adequate long-term storage, installing -20C freezers and clear communication with families.

“Foetuses and babies of any gestation/age are handled with the same respect, rigour and attention as any deceased body,” the report concluded.

While staff described medical containers as “buckets”, the report said the babies were stored correctly in “biocontainment receptacles”.

The report’s authors revealed failures included key records missing or incomplete, forms updated “retrospectively”, CCTV unavailable and families kept in the dark.

A local funeral home refused to co-operate, the review said, although the parlour claims it responded to an email.

Whistleblowers, who further claimed on Monday night the “whitewash” probe failed to interview “key people”, told of their horror after a dead baby was discarded in a “medical bucket” during a mix-up with another child’s corpse in December 2021.

In their 13 page report, investigators provide extensive detail on the mix-up between the two “foetal remains” younger than 20 weeks, named FR1 and FR2, and a funeral parlour.

SA Health asked harrowing details be withheld.

A woman, 69, who died in hospital after a nursing home fall, was then discovered with her body having “turned into liquid”.

The report outlined how a failure of hospital communication with family, and Adelaide University, which the woman wanted to donate her body for research, left her unclaimed in the mortuary for nine weeks.

SA Health chief executive Dr Robyn Lawrence, who headed the inquiry, insisted she had confidence in the hospital’s leadership and patient care.

In an interview on Monday, Dr Lawrence said management accepted responsibility with findings the three families were told about on Monday.

SA Health chief executive Dr Robyn Lawrence insisted she had confidence in the hospital’s leadership and patient care. Picture: NCA NewsWire / Brenton Edwards

“All staff come to work to do the absolute best they can and at times we don’t meet our own expectations. And that is disappointing,” she said.

“It’s always disappointing when we don’t follow procedures that are in place … for a range of reasons.

“However, we’ll have to learn from those and we have to look to the future to ensure that what we can do is better for the next people who come along.”

She said staff were expected to follow rules but said it was “highly unusual” and a “relatively rare occurrence” for two dead babies to be simultaneously stored.

Dr Lawrence, who travelled to Port Pirie and interviewed staff late last year, defended the lack of disciplinary action and said time frames to action change would be negotiated.

“I couldn’t find any direct evidence of misconduct,” she said.

“But I was really focused on actually what happened at the time and how we could improve that for the future.

“They (leaders) are heavily committed to that community. And many of them live in the community. That’s what they’re there for.”

The network’s chief executive, Roger Kirchner, again apologised and said findings would be introduced as quickly as possible.

“We accept all findings … made and most recommendations are already well progressed,” he said in a statement.

Stephen Nygaard, the Royal Adelaide Hospital’s mortuary unit boss and head of SA Pathology’s SA Tissue Bank was a co-author of the report with Women’s and Children’s Hospital mortuary manager Alison Tanner.