This matter has been described by the mainstream media as a
'failure of governance' in Victoria.
Unfortunately there are many more serious instances of a
'failure of governance' by the so called 'authorities' which are deliberately hidden from the general populous.
One aspect of governance is something called policing, where the police are supposed to be here to
protect life and property, but instead are revenue collection agents for a corporation conglomerate called the 'Australian government', which is NOT the same as the de jure government called the 'Commonwealth of Australia', as per the Australian Constitution.
The government has done very little with respect to dodgy doctors in their 'practice'.
Who cares about the deaths of the children of the 'canon fodder' as long as the fines keep coming in, right?
And now it's easier to kill people and leave the country than to dodge an unlawful sheriff's of Victoria warrant arising from the illegal 'Infringements Court'.
From the news.com.au article of 15 October 2015 of the headline:
Bacchus Marsh Hospital investigated over deaths of seven babies
UPDATE: THE former director
of obstetrics at Bacchus Marsh and Melton Regional Hospital had
conditions placed on his medical licence after an investigation that
found the deaths of seven babies may have been avoidable.
Director
of obstetrics and gynaecology, Surinder Parhar, retired from the
Djerriwarrh Health Services, which looks after the hospital, in July
this year.
He had been at the hospital for 30 years.
Conditions
were placed on his medical licence in June following a 28-month
investigation by the Australian Health Practitioners Regulatory
Authority.
This investigation resulted from a doctor lodging a complaint. It is understood Mr Parhar has left the country.
The
Herald Sun is not suggesting Mr Parhar was directly involved in the deaths.
In
what Health Minister Jill Hennessy today described as a “catastrophic
event”, an investigation into Djerriwarrh Health Services found seven of
10 stillborn or newborn deaths in 2013 and 2014 may have been
avoidable.
Five babies died in 2013, and two in 2014.
The
investigation, held by Professor Euan Wallace, found a “number of key
failings at Djerriwarrh Health Services during 2013 and 2014”.
Do you know more, or have you been affected? Contact the Herald Sun newsdesk on 9292 1226 or news editor Elissa Hunt
Despite the high number of deaths the hospital, nor its staff, ever raised an alert.
This
issue came to light when a group of senior clinicians on the
Consultative Council of Paediatric Mortality and Morbidity were
reviewing data when they noticed an unusually high number of deaths.
Australian
Nurses Federation secretary Lisa Fitzpatrick said midwives had raised
concerns over practices at the hospital and claims they were not
listened too.
“Staff are very distressed and disturbed at what’s
happened and there also relieved because we know our members here have
been raising concerns about clinical risk and we passed those concerns
onto the previous hospital’s executive,” she said.
“We also put
those concerns in writing to the Department of Human Services and
they’ve felt their concerns have been dismissed and not taken seriously.
“People want to make sure that what has happened never, ever happens again to any woman or family in this state ever again.”
Ms Fitzpatrick said staff raised concerns about the profile of some of the women giving birth at the regional hospital.
“They
were concerned about the lack of consistency of obstetric and
paediatric cover for women birthing here earlier than 37 weeks,” she
said.
“They have declared themselves to be a level three maternity
service so when you’re having premature babies here at 34 weeks, in
particular when many of these women had serious medical conditions
themselves, they believed they should have been at a tertiary maternity
unit.”
The hospital’s administration has been replaced, while its obstetric services are being overseen by tertiary hospitals.
A further investigation has been launched to determine if the Department of Health should have realised the tragedy earlier.
“What
has happened here has been a series of catastrophic failures by a
number of parties that may have contributed to the very sad loss of
young life,” Ms Hennessy said.
“In 2013/14 there were seven
peri-natal deaths at Djerriwarrh — that is double the number expected,
yet this was overlooked by the clinical leader and the board of
Djerriwarrh.”
Health Minister Jill Hennessy at today’s press conference. Picture: Hamish BlairSource:News Corp Australia
Ms Hennessy said the “shocking failures” at the hospital included inadequate reviews of peri-natal deaths.
“While
Djerriwarrh did review some of the deaths at the time, it did not
review them all. And while some were reviewed, they were inadequate and
the findings were not always actioned,” she said.
The board was not told of some deaths, and there was poor oversight.
Other
failures included staff misreading and misusing foetal surveillance,
and the acceptance of high-risk pregnancies that should have been
referred on.
Ms Hennessy said the hospital had “failed to adjust
or update its practices to respond to rapid population growth in the
region”, but she defended government investments in the health service.
She
said some deliveries should not have been attempted at a service
classified as a low-risk provider, and that staff were inadequately
trained.
Australian Nursing and Midwifery Federation Victorian
secretary Lisa Fitzpatrick said concerns about a lack of staff, policies
and equipment at Djerriwarrh’s maternity services were raised with the
Health Department in 2014.
“Some midwives, and possibly doctors,
had raised concerns with management and left the service in frustration
when their concerns weren’t addressed,” Ms Fitzpatrick said.
“We
know that there were an increased number of births at the service and
this was not proportionately matched by increased staff or
infrastructure.”
Dr John Ballard, who was appointed to the
Djerriwarrh board to oversee the hospital in the wake of the deaths,
said they resulted from “multi-system failure” and there was not one
doctor common to each case.
Bacchus Marsh and Melton Regional Hospital. Picture: Nicole GarmstonSource:News Corp Australia
Ms Hennessy said it was a “truly heartbreaking set of circumstances”, and full support would be given to the families involved.
She said the investigation would be transparent because the families deserved to know the truth about the “shocking failure”.
The affected families may be eligible for compensation.
“I am deeply conscious that nothing can change the past for these families,” Ms Hennessey said.
Ms Hennessy said the impact of the scandal was unimaginable for women already grieving over the loss of their babies.
“After
these women endured the death of their babies, in some circumstances
they weren’t given the information that they sought,” she said.
“It is heartbreaking to think of these women thinking that for some reason the death of their baby may have been their fault.
“It
is absolutely critical that we are able to get every piece of
information around their pregnancies and the births and have that peer
reviewed.”
Senior staff from the Royal Women’s Hospital have been
sent to Djerriwarrh to provide expert oversight and better clinical
training for staff.
Principal at Maurice Blackburn Lawyers Dimitra
Dubrow told 3AW two families had contacted the firm about the deaths of
their babies.
“What they are telling us ... is that they have
been contacted by the Department of Health and advised that the
circumstances surrounding their baby’s death is being looked into and
that the death may have been prevented.
“You can imagine this would be extremely distressing for these families who have already suffered a painful loss.”
The
Australian Health Practitioner Regulation Agency said Mr Parhar had
been investigated after a complaint in 2013 about his care of a mother
after the stillbirth of her baby at the hospital.
Action was taken against the doctor imposing conditions on his registration requiring education and mentoring.
“At
the time, AHPRA and the boards were not advised of abnormally high
peri-natal mortality rates at the health service, or about any concerns
about that doctor’s care of other patients, or concerns about the
quality of obstetric or midwifery care provided at the Djerriwarrh
Health Service,” the statement reads.
AHPRA said the case was not sent to a tribunal because it did not meet the threshold for referral.
CEO Martin Fletcher apologised for the time taken to investigate the complaint about that doctor.
Mr Parhar surrendered his registration on October 1.
AHPRA said it was now launching a wider investigation into other doctors and midwives at the Djerriwarrh Health Service.
“In
late July 2015, AHPRA, the Medical Board of Australia and the Nursing
and Midwifery Board of Australia first learned of wider concerns about
potentially avoidable peri-natal deaths at the health service.
“Immediately,
AHPRA used its powers to require the Djerriwarrh Health Service to
provide information to enable close regulatory scrutiny of care provided
by registered health practitioners at the service.”
It is believed the hospital received significant government funding to help expand maternity services just a year ago.
More than $740,000 was directed towards the maternity services unit in 2014.
The hospital’s maternity services birthrate had doubled in less than a decade.
According to the 2013/14 annual report, 897 babies were born in the maternity unit in that year.
In the 2012/13 financial year, 1016 babies were born and 914 born in the year before that.
It was expected the hospital would be catering for up to 1400 births a year as a result of the expansion.
With AAP