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Safety probe launched following baby death and 3 injured

Rockhampton Hospital. Photo: Chris Ison / The Morning Bulletin
Rockhampton Hospital. Photo: Chris Ison / The Morning Bulletin Chris Ison

What we know

  • There were four serious incidents during child births at the Rockhampton Hospital in the last 12 months
  • One baby has died
  • Three babies have suffered serious injuries
  • The babies were transferred to Brisbane specialists due to the seriousness of injuries
  • Each case was investigated and practices have been updated and improved
  • An independent review has been launched to ensure overall safety
  • The community can rest assured the hospital is considered to be safe at this time

 

EARLIER: AN independent review will be launched into safety systems in the maternity unit at Rockhampton Hospital after the death of a baby and the injury of three others during the past 12 months.  

Central Queensland Hospital and Health Service Chief Executive Len Richards ordered an independent review after the latest incident.  

Mr Richards said potential safety issues were identified after three incidents in 2015.  

"Each of these incidents was reviewed by a Root Cause Analysis, which is designed to identify measures to reduce future patient harm," Mr Richards said.  

"As a result, strict safety measures were put in place such as a requirement for midwives to have all CTG reports reviewed by a second midwife and countersigned."  

The independent review will include the circumstances of each case.  

"Each of the families involved in these incidents has been informed of these issues," Mr Richards said.  

"I offer my unreserved apology to these families and I assure each of them and the community that I will do everything I can to ensure it never happens again."  

UPDATE 4.15PM: LEN Richards this afternoon addressed the media in regards to the launch of maternity unit safety reviews at Rockhampton Hospital. 

"Within the last 12 months we've had four serious clinical incidents in our maternity service here within Rockhampton Hospital," Mr Richards said. 

"Four serious incidents is four too many so I will be commissioning an independent review into the safety systems in the maternity unit. 

"These have been significant incidents. I don't want to go into any of the clinical details, I think suffice to say that the babies themselves were transferred down to Brisbane and have been looked after by tertiary specialists because of the injuries through childbirth.

"We did a review after each and every incident and what we have done is put in improvements in our safety systems that were specific to individual cases. 

"There have been some common themes through the incidents, interpretations of CTGs which is a monitoring of the baby's heart during labour and delivery, escalation between midwives and obstetricians and that sort of thing. 

"An independent review will bring fresh and expert eyes to look at our systems and our service to suggest further improvements for us."

Mr Richards assured the community, specifically expectant mothers, that immediate action was being taken.

"Before we go on I'd like to offer my unreserved apologies to the families affected and I can assure them I and the board will do everything to ensure it does not happen again," he said. 

"I'd also like to reassure the community and those expectant mothers who are using our services that we have taken immediate action, we have higher levels of supervision in the unit, improved and more regular training, better access to obstetricians and the expertise that they bring and a review of our protocols and procedures.

"What we decided on the board today was that because there had been four that were quite similar and quite serious, we wanted to bring in an independent review to have a look at the whole system.

"We're about to commission the review, we want it do it quickly and we'll be talking to the Royal College of Obstetricians and we'll also be talking to expert midwives. 

"I hope to have it up and running in March this year. It will be a big piece of work but we want to have it over and done with as quickly as possible. I think it will be a two to three month period."

Mr Richards said the mothers involved had been notified. 

"We have spoke to two of the mothers of the four to tell them we are launching this review and we've left messages for the other two and will try to contact them as the night goes on," Mr Richards said. 

Executive Director of Medical Services Central Queensland Hospital and Health Services, Doctor David Cooper, said it was important to introduce immediate mitigation strategies. 

"I can assure the community that the service is safe and we have put these strategies in place which includes making sure a specialist obstetrician is immediately available and overseeing the case with the utmost attention ," Dr Cooper said. 

"It ensures more regular ward rounding and pro-activity in the labour ward to ensure that a specialist is there at the bedside when required. 

"It's important also that we've put in these training modules to ensure extra vigilance is taken over the baby monitoring devices."

Dr Cooper said many babies, over 1300, were delivered at Rockhampton Hospital safely every year. 

"We've got an excellent obstetric workforce, we do have excellent midwives and we really want to get to the bottom of these cases with this external review," he said. 

"I can assure the community that the service is ultimately safe."

Topics:  baby death rockhampton hospital



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