Bacchus Marsh Hospital baby deaths: Our saddest scandal

HOW a doctor and Bacchus Marsh hospital failed mums and babies they were meant to protect — and why no one stopped it.

Bacchus Marsh and Melton Regional Hospital. Picture: NICOLE GARMSTON

A FORTNIGHT before she died in May, Lynne Nagy’s biggest wish was to stop the doctor she  held responsible for her dire situation — Dr Surinder Parhar.

After a legal battle, the mum, 63, had just reached an out-of-court agreement with Djerriwarrh Health Services over the care, or alleged lack of, she received from its director of obstetrics.

When she died on Mother’s Day, Mrs Nagy remained unaware secret investigations were just starting to lift the lid on a cluster of baby deaths in Dr Parhar’s maternity unit at Bacchus Marsh and Melton Regional Hospital, or just how many others had also suffered.

“I’d love to see him come back here with everything else he has done with these babies,” Mrs Nagy’s devastated widower Ray Nagy said this week.

“She wanted him struck off. She wasn’t worried about anything else, she just didn’t want him to be able to treat anyone else.

“When it was settled I went back to the hospital and all Lynne asked was, ‘Is he struck off?’. That was all she wanted, she just wanted him to not be able to do this to anyone else.

“To this day I still don’t know how I got her — she is just way above my league and that is why this is so hard to take.”

Suffering bleeding in 2010, Mrs Nagy’s GP referred her to Bacchus Marsh hospital to see a specialist for a hysterectomy after tests showed things weren’t right. In the 18-month treatment she received from Dr Parhar that followed, Mrs Nagy didn’t receive the hysterectomy that might have saved her, nor did the specialist ever diagnose the endometrial cancer that was killing her. By the time another specialist realised what was behind her constant bleeding, the cancer was a stage three disease and little could be done.

While she focused her attention on trying to beat the disease, Mrs Nagy also began legal action against Dr Parhar’s hospital.

When the Sunday Herald Sun revealed Dr Parhar had handed in his medical registration after being at the centre of a scandal over seven avoidable infant deaths at Bacchus Marsh hospital, Mr Nagy was further devastated, though not surprised.

But as more horror claims and secret legal actions emerge, it seems the recent chilling disclosures from Bacchus Marsh hospital may be just the tip of the iceberg.

Once the director of obstetrics at a quiet country outpost, Dr Parhar now sits as a central character in the biggest and saddest scandal in Victoria’s health history.

The other central player identified by health authorities and the State Government so far is “systemic failures”, making it difficult to present any other acceptable answer to the distressed public.

But, with most of the senior staff around him having also been at the Bacchus Marsh hospital for the best part of two or three decades, Dr Parhar is only one piece of a badly broken puzzle.

Even the authorities now gathering evidence and trying to work out how and why things went so badly at Bacchus Marsh — the Australian Health Practitioner Regulation Agency and the Victorian Department of Health — have massive clouds hanging over their heads about why they didn’t know what was happening in Dr Parhar’s unit.

The explanation from those close to the hospital or now involved in the various investigations varies little: when Dr Parhar joined the Bacchus Marsh hospital in the early 1980s the then-bush hospital and its maternity unit was more than capable of looking after the area’s low-risk pregnancies.

Like the unit, Dr Parhar also seemed perfectly suitable to look after the run-of-the-mill pregnancies, having recently qualified as an obstetrician and been first registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 1980.

But as the region turned into one of the fastest-growing areas of the Australia, the hospital, and seemingly its director of obstetrics, remained in a time warp.

Just as Dr Parhar had been at the hospital for about 30 years, so too had its director of nursing Julia Meek, and the nursing manager of the manager women’s unit, Mary Little. And Bruce Marshall had overseen all of them for the past 17 years as Djerriwarrh Health Service CEO.

Serious questions are now being asked about whether they could have done more.

Investigations now paint a picture of an obstetrics and maternity unit sinking more out of its depth as the workload and complexities around it increased.

Recent annual reports reveal the hospital was buckling under the pressure of local population growth and concluding that “the demand to deliver services exceeds our capacity to deliver them”.

By 2014 the Bacchus Marsh hospital was delivering 1000 babies a year, but was still classified as a level 3 maternity unit, limited to dealing with low-risk, non-complex pregnancies.

Mothers with more complex pregnancies are supposed to be referred for more specialised care at the Royal Women’s Hospital or Western Health, where deliveries that may have been dangerous 30 years ago are now routine.

Despite operating in a unit some describe as “archaic” and stuck in the 1980s, it is now apparent Dr Parhar and his team had been continuing to treat women they should have been referring, with tragic consequences.

Those looking into the culture of the maternity service believe the majority of nursing staff and midwives who have worked there have joined straight out of their training, meaning they have never known a different way of operating. Some of the more recently arrived nurses couldn’t ignore the issues though, and raised them in a letter sent by the Australian Nursing and Midwifery Federation to the Department of Health and the hospital.

Tellingly, they questioned why babies as low as 34 weeks’ gestation, and those requiring oxygen, were being admitted to the hospital.

“Their ability to provide evidence-based contemporary midwifery care is compromised by a lack of clear guidelines from management,” the midwifery staff wrote.

But concerns about Dr Parhar were first identified decades earlier, and he gradually gained notoriety.

As far back as the 1980s, patients were slowly beginning to understand that their bad experiences were not isolated.

Mother of two Suzanne Clark spent years coming to terms with the way Dr Parhar handled her miscarriage in 1986. After her foetus passed naturally, she said he “manually removed” her placenta, without pain relief.

“You wouldn’t do that to an animal,” Mrs Clark said.

It was a few years later that she received a call from a woman compiling a dossier of Dr Parhar’s “dodgy practices”.

Mrs Clark said the woman identified herself at the time, and appeared to have medical knowledge, but was never heard from again.

“It makes me feel sick because this (the recent revelations) is all old news to us,” Mrs Clark said.

But she has a simple theory about why Dr Parhar was allowed to keep practising for so long: “Doctors don’t speak about other doctors.”

Mrs Clark said she would do anything to help bring Dr Parhar to justice.

For more than 20 years, others have raised the alarm in courts, though in several instances they have received out-of-court settlements or agreements before a trial.

In others cases, battling families have been unable to afford legal bills after initiating actions. And in some cases the grief has been compounded with couples splitting in the wake of their loss, abandoning their lawsuits as they try to move ahead with their lives.

AFTER her horror 1992 pregnancy, Deborah Simpson took Dr Parhar to the County Court claiming he had left her infertile. When her pregnancy failed, Ms Simpson claims the obstetrician told her she had miscarried, only to find days later she actually had an ectopic pregnancy. She was angry the condition hadn’t been detected earlier, to the point where she was left infertile. Dr Parhar denied the allegations and a trial date was set for August 24, 1998, until it was suddenly discontinued in July.

Another action rose over the 1994 death of Melinda Buchanan’s daughter Maddisyn. Ms Buchanan blamed Dr Parhar for the situation in which Maddisyn’s umbilical cord wrapped around her neck.

In this instance Dr Parhar’s insurers paid $10,500 during mediation in 1999, though Ms Buchanan had to sign a nondisclosure document as part of the settlement.

Legal action also rose over the July 1999 death of infant Brandon Hocking. Mother Laraine Hocking claims that despite repeatedly telling Dr Parhar she wanted to undergo a caesarean birth, he counselled her to have a natural birth. The mother claims Dr Parhar used Kiellands forceps, which caused a brain bleed that killed Brandon. Again, Dr Parhar denied the claims but settled the case during mediation in April 2004.

Mum of two Debra Pum was so traumatised by her experience with Dr Parhar in 1995 that she moved out of Melton “so I didn’t have to drive past his clinic”.

She blames Dr Parhar for failing to detect problems with her pregnancy before the stillbirth of her son, Cory.

But she was also one of many mums who have told the Sunday Herald Sun that nurses and midwives were just as upset by the care being dished out to patients.

“One midwife looked me in the eye and said, ‘Something has to be done’,” she said.

Mrs Pum was quick to defend Mary Little, who eventually became the nurse unit manager. “She was extremely compassionate. She cried with me,” Mrs Pum said.

DESPITE the mounting pile of evidence, it was only in 2013 that the authorities began asking their own questions.

Dr Parhar was investigated by the Victorian Board of the Medical Board of Australia, following a stillbirth. After a 28-month investigation, he was slapped with “conditions” on his registration in June this year. They included taking lessons on teamwork, record keeping and how to handle obstetric emergencies.

Within a month, Dr Parhar resigned and, on October 1, he “surrendered” his registration, 43 years after graduating from Monash University.

No longer able to practise in Australia, he recently flew to India. Dr Parhar’s wife, a physiotherapist, is still in Bacchus Marsh.

Alarm bells about the broader problems at the Djerriwarrh Health Service, which runs Bacchus Marsh and Melton Regional Hospital, began ringing in March.

A single man sitting on an obscure Department of Health subcommittee analysing peri-natal deaths data noticed a similarity between two infant deaths at the hospital, and finally asked the question nobody else had: why are there so many seemingly avoidable deaths at Bacchus Marsh?

After commenting that he was seeing a second similar case come through the Consultative Council of Paediatric Mortality and Morbidity (CCOPMM) process from Bacchus Marsh, a wider examination of infant deaths was triggered.

What was uncovered would later be described by Health Minister Jill Hennessy as a “catastrophic event”.

The closer look had revealed that in 2013 the hospital had seven peri-natal deaths, when a hospital of its size and speciality should see no more than three or four.

It was soon realised the council was actually looking at a cluster of 10 deaths dating back to early 2013, though an 11th could later be added when a separate investigation by the Australian Health Practitioner Regulation Agency was factored in. More startlingly, the usual split between “unavoidable” and “avoidable” deaths had been turned on its head at Bacchus Marsh.

In Victoria there are about 750 stillbirths and 250 neonatal deaths each year.

Nine out of 10 of the deaths are considered unavoidable due to issues such as congenital abnormalities or severe prematurity that are “not compatible with life”.

Of the remaining cases, only a few each year ever have avoidable factors identified that could be directly considered to have contributed to the death.

When they are identified the CCOPMM raises the issue with the hospital, only to find it has usually already been thoroughly investigated.

But in Bacchus Marsh they weren’t dealing with an isolated case, or even two. In an alarming seven of 10 cases the experts found clearly avoidable causes had directly led to the deaths of babies.

Worse, when they raised the issue with the hospital it was realised no investigation had been undertaken into any of the deaths, let alone the tragic cluster.

Within weeks the department dispatched Liz Mullins to Djerriwarrh Health Services for the grim task of knocking on people’s doors to begin Open Disclosure.

Among those was Bacchus Marsh grandmother Merilyn Curran. Mrs Curran had watched on in horror as her daughter-in-law Schazz Curran’s “perfectly healthy pregnancy” turned into a nightmare in November 2013.

Tiffany had been born with anencephaly, and missing parts of her brain and skull.

The fatal deformity was only picked up during a mid-labour ultrasound, not during any of Ms Curran’s pre-natal appointments with Dr Parhar.

WHILE the tragic outcome clearly fell into the “unavoidable” category, the family was shocked and devastated by their treatment at the Bacchus Marsh hospital.

Firstly, the Currans were not told something wrong at first. The only clue was the “room full of strangers” — several student doctors and nurses — viewed the operating theatre when Dr Parhar delivered Tiffany.

Secondly, they were given no warning about the extent of Tiffany’s deformities.

“They put a little white hat on Tiffany’s head, but it fell off when they handed her to me,” the grandmother said.

“Parts of her brain were showing. They didn’t even warn me properly.”

Two days later, Tiffany was sent home with her parents but with very little information about her terminal condition.

“It was more or less ‘get out’,” Ms Curran said.

Tiffany died at home five days later, and the family never again heard from the hospital — or Dr Parhar — other than receiving a $7500 bill because Ms Curran was not covered by Medicare.

Meanwhile, the local communities have been left to deal with the fallout.

Last week a Bacchus Marsh nurse loading her shopping into a car was called a “murderer”. Senior staff have essentially barricaded themselves in their own homes. The partner of one senior staff member claims the hospital and its staff are being made into scapegoats.

But the revelations have left so many people like Melton’s Stewart Merry desperately wondering if a past tragedy could have been avoided.

In 1994 Dr Parhar was looking after his wife Samantha’s pregnancy when everything went wrong.

At 38 weeks the couple became concerned at a slowing of movement in Ms Merry’s womb, and at their final check with Dr Parhar, Mr Merry says they were dealt a brutally cold dose of reality.

“His words were, ‘Your baby has died and you’ll need to go to the Royal Women’s now’. It was just broken to us like that,” Mr Merry said.

“Was it avoidable? Should I have expected more? It’s all a bit shocking really.”

After attending the Royal Women’s Hospital a fortnight later, the couple were told Ms Merry had suffered pre-eclampsia. Now, like many other families who have contacted the Sunday Herald Sun , they are questioning whether Dr Parhar or anyone at Bacchus Marsh should have picked up signs of the condition earlier and saved their baby.

They may never know.

As a result, law firm Maurice Blackburn has more than 40 potential claimants contact it for help.

It is a similar situation at rivals Slater and Gordon, where lawyer Anne Shortall expects a flood of future legal action to follow.

“They had a right to expect that they and their babies would receive the appropriate level of healthcare,” she said.