Investigating Perinatal Deaths: Djerriwarrh Health Services Inquiry

This report delves into the tragic case of perinatal deaths at Bacchus Marsh Hospital, examining the failures in clinical governance and safety standards that contributed to the unacceptable loss of infant lives. The analysis focuses on breaches in key domains such as workforce management, clinical practice, and adherence to safety and quality guidelines. The report identifies specific issues, including misinterpretation of cardiotocography observations, inadequate incident reporting, and a lack of proactive risk management strategies. Strategies such as improved credentialing, thorough auditing, and responsive complaint handling are discussed as potential measures to prevent similar incidents in the future. Ultimately, the report underscores the critical need for robust clinical governance and a commitment to patient safety within healthcare organizations to ensure the well-being of vulnerable patients.

Running head: PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
Perinatal Deaths in Bacchus Marsh Hospital
Name of Student
Name of University
Author Note

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Table of Contents
Introduction:....................................................................................................................................3
Discussion:.......................................................................................................................................3
Clinical Governance:...................................................................................................................3
Workforce:...............................................................................................................................4
Clinical Practice:......................................................................................................................5
Safety and Quality Guidelines:....................................................................................................5
Strategies to avoid Risk Management:........................................................................................6
Conclusion:......................................................................................................................................7
References:......................................................................................................................................8

3PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
Introduction:
The case of perinatal baby deaths Bacchus Marsh hospital has been highlighted recently
for its absurd number of still born baby deaths over the span of ten years. Proper assessment of
the reports provided by Djerriwarrh Health Service, has showed that the death cases could have
been avoided with medical assessment. The report aims to address the lack of clinical
governance and safety standards regarding this case (Renfrew et al., 2014). .
Discussion:
Clinical Governance:
It is defined as the structural and systematic standard practices applied to create a custom,
which will govern clinical activities. Clinical accountability and responsibility, is a sub-set of
clinical governance, involving the supervision and omission of clinical activities, including
regulation, auditing, assurance and compliance by boards of directors, governments and
professional bodies et cetra.
There are five domains which constitute effective clinical governance:
1) Culture and leadership
2) Consumer relationship
3) Workforce
4) Management of Risk
5) Clinical practice

4PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
A number of articles suggested that out of 96 cases that were referred to AHPRA about the
scandal, together with those relating to 13 doctors, 23 midwives and nurses and four other
medical staff suggested that two of the five domains were breached. The respondent practitioners
and other staffs failed to manage risk suggesting inefficient workforce and erroneous clinical
practice.
Workforce:
Organizations need to ensure that employees should have basic knowledge and
appropriate skills to fulfill their duties and perform their respective responsibility within an
organization. Processes should be prepared to bear recruitment, training accountability and
maintenance of standard clinical trials. The strategies undertaken to ensure maintenance of
workforce include:
1. Appropriate qualifications should be a part of health workforce.
2. Planning and scheduling of quality development should be implemented.
3. Staff communication is important to maintain clinical standards.
According to a report provided by the perinatal baby deaths in the Bacchus Marsh
hospital was a result of misinterpretation of a cardiotocography observation, which is an
instrument for observing fetal heartbeat and uterine contraction in a pregnant woman.
Investigation lead by the Australian Health Practitioner Regulation Authority revealed that five
practitioners were failed to provide proper medical assessment and immediate action was taken
against them.

5PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
Clinical Practice:
The clinical practice principles contain statements that include standard regulations,
strategies, or instructions that assists health practitioners and nurses make decisions about
appropriate health service for specific clinical circumstances (Brennan, 2013).
The report provided Department of Health and Human Services reflects that practitioners
and other medical staff of Bacchus Marsh campus failed to meet standards of National Safety
and Quality Health Care. The hospital staff failed to record the incident and provide the report
which would draw attention from higher authority. Failure to assess clinical symptoms shows
inefficiency of the staff as well as practitioner (Devers et al., 2013).. The time span of increase in
number of perinatal death reflects the indifference of the hospital staff.
Safety and Quality Guidelines:
Management of Health service organizations implement governance systems to consign,
check and develop the performance of the organization and correspond to the importance of the
patient understanding and quality management for all members of the workforce. Health
practitioners and staff members of the workforce contribute to the governance systems (Bismark,
2013).
According to a report provided by Dr. Euan Wallace was recruited by the Australian
Department of Health and Human Services to examine the situation, and found that several of the
perinatal deaths could have been avoided if safety and quality guidelines were followed. His
report had several clauses that would breach the safety and quality guidelines. The patients in
labor were not treated with precaution and misinterpretation of analytical equipments show that

6PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
the patient handling staff did not follow the given patient handling standards of the Victorian
government.
Strategies to avoid Risk Management:
The following strategies could have been undertaken to avoid the occurrence of the
incidents in Bacchus Marsh hospitals.
 Credentialing: It is the process undertaken which establishes the qualifications of
licensed medical practioners and staffs and assesses their background and legitimacy
(Freud, et al., 2015). The authority of the Bacchus Marsh hospital failed to recruit quality
staff, which is evident from Dr. Wallace’s report and several other investigative
porcediures.
 Reporting and acting upon near misses and incidents: Health firms have preconceived
plan of action when it comes to near miss reporting. Many such incidents occur that
might surpass a narrow escape from fatality. Reports of the baby deaths, provided by the
Bacchus Marsh hospital coroner show that all the baby deaths were avoidable and not all
the cases were completely fatal (Renfrew et al., 2014). The respondent practitioners and
nursing staffs failed to react in time.
 Accreditation and benchmarking: The accreditation of a hospital is measured by the
number of successful patient cases. In the case of Bacchus Marsh hospital, the Melton
Regional Hospital falls under the same governance of the Djerriwarrh Health Services,
but the latter showed improved patient care and quality assurance than Bacchus Marsh
Hopsital (Gallagher & Mazor 2015).

7PERINATAL DEATHS IN BACCHUS MARSH HOSPITAL
 Auditing: It is the procedure that an organization undertakes which conducts inspecting
the issues, to implement improvement in any aspect of the organization (Goldacre &
Heneghan, 2014).. Several investigations and reports provided by the Australian
Department of Health and Human Services, show that the hospital authority failed to
document any record of the perinatal deaths and tried to contemplate a plan of action. The
number of perinatal deaths would not have increased so much if the staff and
practitioners reported to the health service providers.
 Monitoring and responding to complaints: The health departments have enforced
several misconducts on the Bacchus Marsh hospital authority. One of those allegations
were done because, inspite of the attempts to draw attention of the authority regarding the
perinatal deaths, the authorities failed to achknowledge the issue. It was revealed that
dozens of families have pursued legal action against Djerriwarrh Health Service,
suggesting a multimillion-dollar settlement with the government's insurer is in the works.
Conclusion:
The perinatal death incidents in Bacchus Marsh hospital is a tragic example of lack of clinical
governance and safety and quality standards. The investigative reports showed a number breach
of hospital management modules including clinical malpractice, safety and quality issues,
inefficiency of leadership and management authority and distressed organizational structure
(Hoang, Le & Terry (2014).

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References:
Bismark, M. M., Spittal, M. J., Gurrin, L. C., Ward, M., & Studdert, D. M. (2013). Identification
of doctors at risk of recurrent complaints: a national study of healthcare complaints in
Australia. BMJ quality & safety, http://dx.doi.org/10.1136/bmjqs-2012-001691
bmjqs-2012.
Brennan, N., & Flynn, M. (2013). Differentiating clinical governance, clinical management and
clinical practice. Clinical Governance: An International Journal.
http://dx.doi.org/10.1108/14777271311317909, 18(2), 114-131.
Devers, P. L., Cronister, A., Ormond, K. E., Facio, F., Brasington, C. K., & Flodman, P. (2013).
Noninvasive prenatal testing/noninvasive prenatal diagnosis: the position of the National
Society of Genetic Counselors. Journal of genetic counseling, DOI 10.1007/s10897-012-
9564-0 22(3), 291-295.
Freud, L. R., Escobar-Diaz, M. C., Kalish, B. T., Komarlu, R., Puchalski, M. D., Jaeggi, E. T., &
Michelfelder, E. C. (2015). Outcomes and Predictors of Perinatal Mortality in Fetuses
With Ebstein Anomaly or Tricuspid Valve Dysplasia in the Current EraCLINICAL
PERSPECTIVE: A Multicenter
Study. Circulation, doi.org/10.1161/CIRCULATIONAHA.115.015839 132(6), 481-489.
Gallagher, T., & Mazor, K. (2015). Taking complaints seriously: using the patient safety
lens. BMJ Quality & Safety, 352-355. http://dx.doi.org/10.1136/bmjqs-2015-004337
24(6), 352-355.

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Goldacre, B., & Heneghan, C. (2014). Improving, and auditing, access to clinical trial
results. BMJ (Clinical research ed), 10.4236/jssm.2015.86086 348, g213.
Hoang, H., Le, Q., & Terry, D. (2014). Women's access needs in maternity care in rural
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