A culture of “fear and intimidation” combined with a backward system was behind a spate of infant deaths at a regional Victorian hospital, according to the nurses’ union.
Fairfax Media has been told that walking into the maternity ward at Bacchus Marsh and Melton Hospital was like stepping back in time.
Djerriwarrh stillbirths could have been avoided
Victorian Health Minister Jill Hennessy explains the devastating finds of Professor Euan Wallace’s report into the high number of baby deaths at a Bacchus Marsh hospital. Vision courtesy ABC News.
Only last year, it had outdated equipment, old-fashioned nurse working arrangements that compromised patient care and poor data analysis.
Australian Nursing and Midwifery Federation Victorian secretary Lisa Fitzpatrick said the hospital’s nurses and midwives were labelled “troublemakers” if they sought to contact the union about these concerns.
“It was really a culture of fear and intimidation rather than one that was supportive of a learning environment,” she said.
“They believed if they contacted the union they were putting at threat the maternity services continuing.”
Ms Fitzpatrick said they were “strongly encouraged” not to report clinical risks or make reports to regulator the Australian Health Practitioners Registration Agency.
She said part-time workers could be knocked back for additional shifts, while full-time staff could miss out on promotions for reporting poor practice.
A Health Department probe, revealed on Friday, into 11 stillbirths or deaths in 2013 and 2014 at the hospital, run by Djerriwarrh Health Services, found that its practices could have contributed to seven infant deaths.
The regulator had previously launched a 28-month investigation into the former director of obstetrics Dr Surinder Parhar after concerns were raised about his care of a mother who had a stillbirth in 2013.
After the investigation, Dr Parhar had restrictions placed on his practice, by which time he had already left the hospital. He was struck off the register when his licence expired about two weeks ago.
Since then many more families who have lost their babies or suffered traumatic births spanning decades under Dr Parhar’s care have come forward.
Dr Parhar could not be contacted for comment.
It appears the hospital also had entrenched operational problems that contributed to its poor record.
A letter to the hospital from the union on January 17 last year stated that staffing levels had not kept up with a doubling of births the previous five years.
This had occurred as the hospital reported a $1.9-million surplus in 2012-13, the letter noted.
Ms Fitzpatrick said the “extraordinary pressure” on the hospital as births increased had contributed to the deaths.
Fairfax Media understands midwives were directed to treat births as if they were normal, in spite of complications.
Meanwhile, data from the ward’s births and deaths wasn’t analysed to look for potential issues or areas for improvements.
Statewide government-collated data takes a number of years to be released, meaning issues in the hospital weren’t picked up until too late.
“For the department to be made aware in March 2015 of a cluster of deaths that happened in 2013, that time frame is unacceptable,” Ms Fitzpatrick said.
“There have been a multitude of issues that have led to this complete system breakdown and this tragic outcome.”
The regulator was criticised on Friday for not alerting the department of its investigation but claims it was not aware of a wider problem.
It has since widened the investigation’s scope to include other doctors and midwives at the the hospital.