AUSTRALIA: Baby deaths: Victoria overhauls health services after damning Djerriwarrh Health Services review

October 2016; The Victorian Government has announced an overhaul of the state’s health services after a damning report found a number of baby deaths at a hospital north-west of Melbourne were potentially avoidable.

The review found 11 cases of potentially avoidable newborn and stillborn deaths at the Bacchus Marsh hospital, which is operated by Djerriwarrh Health Services.

The review found the Department of Health failed to provide adequate oversight of quality and patient safety over the past 10 years, and staff cuts and a lack of monitoring resulted in problems being overlooked.

Health Minister Jill Hennessy said the significant reforms would include a new agency, Safer Care Victoria, to monitor quality and safety.

“This will be the biggest overhaul of quality and safety that’s ever occurred,” she said.

“They are critical reforms if we are to give dignity to the awful tragedy of Djerriwarrh and to learn all of those lessons, we need to make sure we put in place the sorts of systems and expert oversight to prevent this from ever happening again.”

The agency will be headed by clinician and researcher Professor Euan Wallace, Ms Hennessy added.

‘These are things that we can change and should change’

Dr Stephen Duckett, who chaired the review, said hospital boards were left to manage their own safety issues, without department oversight.

“There wasn’t enough learning from each other, there wasn’t enough information being provided so the hospitals know how they’re tracking against the rest of the state,” he said.

“These are things that we can change and should change.”

Two maternity units have also closed and another two have been downgraded as a result of a separate review.

Kathryn Booth, head of medical negligence at Maurice Blackburn lawyers, said nothing would take away the victims’ pain.

“However, they will be pleased to see that there’s going to be a big overhaul of the public health system and the very fulsome review by the Andrews Government,” she said.

“It’s really important that the focus be on patient safety and justice for those patients and not further bureaucracy.”

The Government replaced the Djerriwarrh Health Service board and appointed a new chief executive following the initial investigation.

All case notes have been handed to the Australian Health Practitioner Regulation Agency (AHPRA) for investigation.

In June, Health Services Commissioner Dr Grant Davies said his office was assisting 43 women over birth-related concerns and the quality of care they received at Djerriwarrh Health Service.

Those complaints relate to incidents dating back to 1990.


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