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Statement On Djerriwarrh Health Services

14 April 2016

A review of stillbirths and newborn deaths at Djerriwarrh Health Services going back to 2001 has now been completed.

Throughout this process my primary concern has been that the women and families involved were provided with accurate information about the care they received, in a very safe and supportive environment – before any public statements were made.

Today, I can confirm the women involved have received the full facts about their individual cases.

This is a very sensitive and personal matter for the women and families involved, and to ensure the privacy of the women and their families is protected, I am unable to reveal specific details of individual cases.

The review was conducted by independent obstetricians, including Professor Euan Wallace. It followed the same peer review process as the first investigation into stillborn and newborn deaths in 2013 and 2014 at Djerriwarrh Health Services.

It found that between 2001 and 2012, there were 26 neonatal and stillbirths at Djerriwarrh Health Services.

Of these 26 deaths, the review found that four were potentially avoidable as a result of deficiencies in the clinical care provided by Djerriwarrh Health Services.

The deficiencies in care are similar to the deficiencies identified in Professor Wallace’s review of stillborn and newborn deaths in 2013 and 2014.

There is also a case where there was insufficient information relating to the care the woman received before she arrived at Djerriwarrh Health Services to complete the review of this case.

The care provided outside of the hospital is now the subject of separate investigation.

For legal and privacy reasons I am unable to provide any further detail about this case at this time.

The Government has also been made aware of a further case that occurred at Djerriwarrh Health Services in the second half of 2015, that has previously not been public. This case has been reviewed by independent obstetricians and was found to be unavoidable.

This brings the total number of stillbirth and newborn deaths at Djerriwarrh Health Services from 2001 until today to 38 deaths, of which 11 were potentially avoidable due to failures at Djerriwarrh Health Services.

This is 11 lives lost that could potentially have been avoidable.

I extend my deepest condolences to the women and their families involved.

Every woman who experienced a potentially avoidable loss has been given a full explanation of the care she received and has undergone open disclosure or conciliation processes in a safe and supportive environment.

While this review has been underway, there have also been a number of women who contacted the Health Services Commissioner seeking an investigation into the circumstances regarding their baby’s death and the care they received at Djerriwarrh Health Services.

Some of these women lost their baby between 2001 and 2012 – the period the review covered – and these women who contacted the Health Services Commissioner have also received a full explanation about their individual cases, and the care they received.

Every woman who has contacted the Health Services Commissioner about the care they received – is having, or has had – each complaint, concern and case independently reviewed by the Health Services Commissioner.

This will continue until every case has been assessed.

The Government has provided additional resources to support the work of the Health Services Commissioner to appropriately and sensitively manage and investigate each and every complaint they receive.

All cases have also been referred to AHPRA for review.

We have taken steps to ensure new leadership at both a clinical and governance level at Djerriwarrh, and put in place a series of measures to make the hospital as safe as it can possibly be.

This includes greater staff training and oversight, and support from experts at Western Health and the Royal Women’s Hospital.

We are also doing everything we can to ensure the ongoing sustainability of Djerriwarrh Health Services.

The Victorian Budget 2016/17 included significant funding to strengthen quality and safety in rural and regional health services, such as Djerriwarrh Health Services.

As part of this package, specialised training programs relating to emergency management and maternity care led by the Royal Women’s Hospital will be rolled out to smaller rural health services across the state.

State-wide incident reporting and response management systems will also be strengthened, and a state-wide review of quality and safety in the Department and across the health system is currently underway.

We are doing everything possible to prevent this from ever happening again.

Reviewed 19 August 2020

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