Investigation into baby death exposes flaws at Latrobe Regional Hospital
A coroner’s medical report into the heartbreaking death of a baby in one of the state’s hospitals revealed the infant suffered from unexplained head injuries, raising questions about how an internal review cleared hospital staff of any fault.
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A horror death of a baby in a Victorian maternity unit has exposed major flaws in the health system.
The baby died during delivery at Latrobe Regional Hospital in March 2019, with its distraught parents fighting for answers ever since.
An internal review by Latrobe Regional Health immediately after the death cleared medical staff, including the obstetrician, of any fault.
But, last December, a coroner’s medical report identified that the infant died from shocking unexplained head injuries suffered during its birth.
A subsequent investigation launched by watchdog Safer Care Victoria has uncovered potential holes in the staffing levels and abilities of senior medical staff at the Traralgon hospital’s obstetrics unit, which delivers about 900 babies a year.
The case has also raised serious questions over the monitoring of hospital deaths and serious incidents, classified as sentinel events.
Latrobe is now being forced to overhaul its maternity unit, as the investigation found doctors may have acted outside the scope of their practise.
The boy’s parents told the Herald Sun they did not want to comment on the case until the investigation’s final report is delivered in the coming weeks.
They have fought for more than a year to gain answers about why their child died, it is understood.
Latrobe Regional Hospital chief executive Peter Craighead said he was awaiting the findings of a separate full coronial investigation.
He assured the community the obstetrics and maternity teams were safe and qualified.
“We have also looked closely at the level of experience in our obstetrics team and the capacity of staff to manage challenging and complex births. I can assure the community our team is suitably qualified and credentialed,” Mr Craighead said.
“Our internal investigation identified areas for improvement including better communication with parents about the risks associated with complex births, enhanced education on the use of birthing instruments and the need for more monitoring equipment in birthing suites.
“These recommendations were immediately actioned.”
Mr Craighead confirmed an independent SCV review had now highlighted more areas for improvement in the obstetrics unit, but he insisted Latrobe operated at the competency levels and standards required of a Level 5 maternity service.
“Our obstetricians and midwives are passionate about their profession and the loss of a child in their care affects them deeply,” he said.
But the SCV investigation is understood to have raised serious questions about the unit and monitoring processes.
Because the baby’s March 2019 death was classified as a sentinel event, LRH was automatically required to review the fatality.
The hospital initiated a root cause analysis which did not find serious issues over the way the birth was handled.
And only after the baby’s parents pushed for further investigation did a December coronial medical report find the child had died from massive head injuries.
The finding prompted SCV – established in the wake of the Bacchus Marsh Hospital baby deaths scandal – to initiate an independent review.
The Herald Sun understands SCV’s interim report found there was no evidence that the obstetrician was qualified to perform the type of delivery undertaken during the March 2019 tragedy.
Significant concerns are understood to be held regarding whether forceps or other instruments were used appropriately during the complex birth.
The SCV report has also revealed the hospital had insufficient systems in place to assess whether its medics had the qualifications or ability to perform such births.
While LRH has been accredited as a Level 5 maternity service – requiring senior medical staff to undertake “moderate-risk pregnancies” – SCV found it did not employ a 24-hour registrar as demanded by Victoria’s maternity and newborn framework, who could have assisted during the delivery.
Although the SCV investigation has not found LRH whitewashed its internal examination of the death, it found the hospital’s review did miss issues connected to the birth.
The discovery led to a recommendation for SCV to overhaul its own processes to better scrutinise hospital internal reports and to not just accept their root cause analysis on face value.
Health Minister Jenny Mikakos told the Herald Sun that although the review was still being finalised, the hospital and department were already implementing improvements identified in the interim report.
“The loss of a child is an unthinkable tragedy. Our hearts and sincere condolences go out to the family,” Ms Mikakos said.
“Safer Care Victoria and the Department of Health are working closely with Latrobe Regional hospital to ensure any lessons that need to be learned from this tragedy are brought to light and acted on in full.”
But Opposition health spokeswoman Georgie Crozier said wider questions remained over the hospital’s accreditation and oversight.
“This is such a sad and tragic outcome for the family who understandably want to know why this happened,” Ms Crozier said.
“The Health Minister Jenny Mikakos needs to be totally transparent on this issue and needs to assure this community and all Victorians that our health services are safe.”
In light of the grim findings, Monash Health Service has been called in to oversee Latrobe’s maternity unit and provide “senior support and supervision” to it’s obstetrics team.
In response to other recommendations, Latrobe has appointed a registrar, purchased additional foetal heart monitors, overhauled its decision making processes and increased “simulated” training for its staff.
The hospital is also trying to hire new staff to increase its maternity workforce.
The Herald Sun understands the Australian Health Practitioner Regulation Agency is also investigating the obstetrician and other LRH medical staff over the birth, though a spokeswoman said they could not comment on individual cases.
“Public safety is our priority and we take all notifications seriously,” the AHPRA spokeswoman said.
“Our inquiries in relation to the matter are ongoing and we cannot comment further at this time.”
A DHHS spokesman said the department was monitoring the review and working with the hospital to make further improvements ahead of the final report.
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