The Herald Sun can reveal Victoria’s peak doctors’ group has been urging the state government for several months to act after its healthcare safety office — Safer Care Victoria — was left in the dark about cases of serious, sometimes fatal, issues in children’s care.

Health authorities say the current system relies on hospitals reviewing themselves and self-reporting any deaths to SCV.

It comes after revelations the Royal Women’s hospital never reported the death of a newborn baby to Safer Care Victoria, despite a coroner last month finding that earlier treatment may have saved the infant.

Health services are required to report serious adverse incidents, known as ‘sentinel events’ to Safer Care Victoria (SCV), which was set up in 2016 in the wake of a cluster of baby deaths at Bacchus Marsh hospital, first revealed by the Herald Sun.

But the Australia Medical Association’s Victorian branch has warned the state’s health system still lacks “consistent oversight and reporting” of avoidable child death and harm.

It is calling for a new rule that would require hospitals to notify all unexpected, or healthcare associated, child deaths to SCV regardless of whether they believe it is a sentinel event or not.

President Dr Jill Tomlinson says despite raising their concerns with the government on several occasions, their plea for reform has been ignored.

“As a parent, I would like to think that in Victoria, we are doing absolutely everything that we can to reduce healthcare associated harms to all people, but particularly children, and we do need to strengthen the health systems accountability,” she said.

Dr Tomlinson said she was aware of “multiple instances” where a child’s death was not reported as a sentinel event to SCV, but “many individuals, clinicians and the Department of Health” believe it should have been.

“If all the sentinel events were reported, that would give us a much better opportunity to understand where the gaps and system errors are in Victorian healthcare.”

Some sentinel events must also be reported at a national level, but in a damning submission about using that data, the Victorian health department admitted SCV’s assessments were “reliant” on information from hospital’s internal reviews.

The comments, discussing a federal funding policy that penalises hospitals for some sentinel events incidents, were made in a submission to the Independent Hospital Pricing Authority mid-last year.

“Safer Care Victoria does not sit on the review panels, which means making the assessment on avoidable events is reliant on the information provided,” a department submission said.

Most members on the review panels are hospital staff.

The submission also said some of the criteria used to identify sentinel events - such as if the failure caused a patient to require life-saving treatment - could have different interpretations.

“Victoria faces challenges with the consistency in definitions and variability in reporting sentinel events and hospital acquired complications,” the submission read.

“For example, the definition of what life saving surgical and medical treatment is can be widely interpreted.”

Dr Tomlinson said it was a “serious concern” when cases were not reported to SCV and there was a “high probability” that unexpected child deaths in healthcare were sentinel events.

“(If reported) They can all be reviewed and recommendations made that would potentially improve healthcare for Victorian children and prevent future injury and death.”

The association is also calling on the department to issue guidelines to hospitals about their communication with families who lose a child in such circumstances, saying there was “room to improve”.

Dr Tomlinson said she wrote to Health Minister Mary-Anne Thomas in November, and met with SCV in December, but their “responses to date don’t leave” her to think they will “act any time soon” on the proposal.

“Absolutely everything possible must be done to … ensure that the deaths are subjected to timely and transparent reviews and families supported compassionately and communicated with openly and honestly” she said.

Baby Amir’s case is now one of several child deaths to emerge where a hospital failed to notify SCV or ran an internal review now facing serious questions.

Max McKenzie, 15, died in 2021 after Box Hill Hospital took more than 15 minutes to intubate him in a case that senior health officials considered a sentinel event.

But his father, an emergency doctor, was forced to report his own’s son death to SCV after the hospital failed to do so and, in an internal investigation, cleared themselves of blame.

Noah Souvatzis died from sepsis meningitis in 2021 after a series of failures at Northeast Health Wangaratta, who dismissed his parents concerns and discharged the clearly unwell toddler.

Coroner Katherine Lorenz ruled his death was preventable and said the hospital’s earlier review, done alongside the Royal Children’s, had “fundamental and obvious flaws”.

Noah’s death was reported to SCV but Coroner Lorenz noted their role was “advisory”, “not regulatory” and the “onus” to “adequately investigate” sentinel events was on the individual health service.

She found key staff were never interviewed, and the concerns of Noah’s parents were, again, not addressed.

A SCV spokeswoman, when asked how patients could trust an office that was reliant on hospitals to self-report, said health services “were required” to notify them.

“We work closely with them on reporting of all unexpected deaths so that any lessons can be shared across the health system and prevent future harm,” she said.

“We work with stakeholders to continuously strengthen and improve our reporting processes and available resources for health services.”

The government, asked similar questions about SCV’s abilities in the wake of several unreported, or poorly investigated, deaths by hospitals, said Victoria had the “most stringent reporting, accountability and transparency environment in the country”.

“The death of any child is a tragedy,” a government spokesman said.

“It is our responsibility to learn from them and maintain a health system that is safe for every Victorian – that’s why we established Safer Care Victoria.”

Jacinta Allan on Monday conceded the government needed to do more to boost transparency in Victorian hospitals.

The Premier said Health Minister Mary-Anne Thomas had requested both Safer Care Victoria and the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) to provide advice on how the government could strengthen hospital reporting frameworks to ensure cases were properly investigated.

Ms Allan said the revelations in the Herald Sun were concerning but that she would await fresh advice before outlining how the government planned to respond.

“I am concerned,” she said.

“It gravely concerns me as a Premier, gravely concerns me as a mum and someone who spent a lot of time in neonatal wards when my little girl was young.

“The death of any child is a tragedy, and particularly my thoughts are with little Amir’s family who have gone through such a terrible, awful experience no parent would wish on (any) parent.

“I’ll make it very clear ... If there is more that we need to do, we will do it.”

Ms Allan hinted at supporting the Australian Medical Association’s calls to require hospitals to notify Safer Care Victoria of all unexpected deaths, rather than just cases deemed to be a sentinel event.

“This does seem to be at the heart of one of the issues,” she said.

“It is important that families who have lost their loved one understand what has gone on.”

Describing the Premier and health minister as “Incompetent and out of their depth”, opposition health spokeswoman Georgie Crozier said, “There needs to be a thorough and independent inquiry” following the tragic deaths.

“There is mismanagement right across the system that is leading to very serious and tragic consequences,” Ms Crozier said.

“We have had too many stories of babies tragically dying and Safer Care Victoria not undertaking the investigative work that they need to,” she added.