Max McKenzie died in hospital. His family are warning there is ‘nothing to stop’ next the Bacchus Marsh baby scandal

Family warns there’s “nothing to stop another Bacchus Marsh”, one of the deadliest patient scandals, after hospitals left officials in the dark about several child deaths.

Max McKenzie, 15, died in August 2021. His death is now considered a ‘sentinel event’. Picture: Supplied

The government is “seeking advice” on hospital’s reporting of patient deaths after conceding it needs to do more to improve transparency.

The Herald Sun revealed on Monday that Safer Care Victoria was left in the dark about several child deaths because the treating hospitals, in a decision at odds with other experts, ruled there were no issues to justify a sentinel event report.

Jacinta Allan announced the informal review hours after this masthead revealed that doctors were pleading for change and another potentially avoidable death, a newborn named Amir, had gone unreported for years.

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

The government said the work was already underway but did not answer why, if this were the case, they did not mention it when repeatedly asked about the issue before Monday.

A review into the cluster of avoidable baby deaths at Bacchus Marsh Hospital led to the creation of Safer Care Victoria.

It comes as grieving parents warned reforms introduced after a cluster of baby deaths at Bacchus Marsh Hospital would still fail to stop the same tragedy if it happened today.

SCV was created in 2016 amid changes promised to improve transparency and the department’s oversight of hospital safety.

But when Tamara and Ben McKenzie’s 15-year-oldson Max died in 2021 after an allergic reaction, Box Hill Hospital repeatedly dismissed their concerns, forcing them to report his death to SCV.

Dr McKenzie, an emergency physician, said Max should be alive but the hospital waited too long to intubate him.

“Max’s death would never have been reported if I hadn’t been a doctor and been there,” Dr McKenzie said.

He said when they spoke out last year, the government’s response had completely failed to understand that, and called on the health minister to “take responsibility for her department”.

“There’s nothing to stop another Bacchus Marsh happening,” he said.

Ms McKenzie said: “the government needs to recognise that SCV is not doing everything it needs to do.”

Eastern Health has previously said they were co-operating with the coronial process but declined to comment further on Max’s case.

Tamara and Ben McKenzie, with daughters Ella and Lucy, hold a photo of their son Max, who died when he was just 15. Dr McKenzie says Victoria has ‘nothing to stop another Bacchus Marsh’ baby scandal after he was forced to report their own’s son death to SCV. Picture: Jake Nowakowski

The McKenzies support the local Australian Medical Association’s push to require Victorian hospitals report all unexpected and healthcare-associated child deaths to SCV.

The latest data, from the 2023 financial year, shows almost 80 per cent of sentinel events were not reported to SCV within the required three business days, though the real numbers may be higher if incidents that were never reported were added.

Opposition health spokeswoman Georgie Crozier said there needed to be a “thorough and independent inquiry” and “mismanagement” across the system was leading to “tragic consequences”.

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

Ms Allan hinted at supporting the AMA’s proposal, but said she would await fresh advice.

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

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

“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.”