Deaths Report: WDHS says findings ‘not an accurate reflection’

The Hamilton Spectator – October 22, 2015

HAMILTON Base Hospital has achieved one of Victoria’s “poorest results” for its death rate of babies born prematurely but the finding “does not accurately reflect performance over recent years”, according to Western District Health Service.

A Victorian Department of Health analysis of perinatal deaths between 2008 and 2012 found that babies born between 22 and 32 weeks gestation at WDHS were 80 per cent more likely to die than the state average.

The report stated that “in interpreting these ratios, conclusions cannot be drawn about avoidability of any of these deaths”.

The report was published in August but The Age newspaper highlighted some of its data this week in an attempt to link other hospitals with a major investigation into baby deaths in Bacchus Marsh.

A review into 10 baby deaths over two years at Djerriwarrh Health Service,
Bacchus Marsh found that seven of the deaths may have been preventable.

Since the review was released earlier this month a number of women, families and former staff have come forward with allegations of clinical incompetence and bullying at Djerriwarrh.

The Age described WDHS as one of a number of Victorian hospitals “on par with or worse than Bacchus Marsh.”

A statement from the offi ce of Victorian Health Minister Jill Hennessey said all Victorian perinatal deaths over the past seven years had been reviewed “and no other health service has been identified as being of concern”.

“Sadly, no pregnancy or birth is completely risk free, and complications
sometimes arise unexpectedly during labour or after delivery,” the minister’s statement said.

“However, latest figures show that Victoria’s perinatal mortality rate is
one of the lowest in Australia.

“The Government has put in place a range of new measures across the
state to ensure the safety of maternity

Though the perinatal report concerned the health outcomes for all babies,
WDHS only had a data entry for babies born at between 22 and 32 weeks gestation.

Babies born at this stage of a pregnancy are defined as “very” or “extremely” preterm and babies born at 22 weeks are unlikely to survive.

The Spectator understands that less than five babies born after 32 weeks gestation have died within 28 days  of birth at WDHS between 2008 and 2012.

That low number of deaths is the reason why WDHS did not receive an
analysis for deaths during treatment of routine pregnancies.

A statement from WDHS said it provided “a quality learning environment and has established processes in place to monitor the outcome of all births, including all perinatal deaths”.

“A medical specialist reviewed the perinatal deaths that occurred at WDHS between 2006 and 2011 and made a number of recommendations that have been actioned.”

The report, ‘Victorian perinatal services performance indicators
2012–13’, stated that health services that performed below average with
health outcomes for babies and mothers “must understand the extent
of suboptimal performance issues and address these”.

Pregnancy terminations and “deaths due to congenital anomalies” were not counted in the data, which was adjusted for the size of each hospital.

According to the report, 230 women gave birth to a total of 232 babies at WDHS during 2012.

WDHS chief executive Rohan Fitzgerald said he recognised the importance of the report as a measure over the period, but it did not accurately reflect the Health Service’s performance over recent years.

“The (gestation standardised perinatal mortality ratio) is an internationally recognised measure of perinatal mortality that includes all deaths, including extremely premature babies, still births and newborn deaths. It does not assess the potential avoidability of any of the deaths,” he said.

“I am deeply saddened for any family that goes through the experience of
losing a baby during labour or after a delivery.

“With every birth our aim is to reduce the risks for both mother and baby as far as practical, although we know that in some cases the risks remain high.”

Despite Ms Hennessy’s statement that no health services were a concern
in regards to baby death rates, the Victorian Government will move to
establish new reporting mechanisms and specific targeting of regional
pregnancy outcomes.

A state-wide perinatal autopsy service will be established along with perinatal morbidity and mortality committees in each region.

“This expert committee will review any perinatal death occurring in that
region every three months,” the Health Minister’s statement said.
“The Department of Health and Human Services will review all of the state’s perinatal services to identify if any improvements can be made.”

Australia’s medical practitioner registration board, AHPRA, which is
in charge of handling complaints about doctors and surgeons, will get a new notification service to automatically inform health services about
investigations into their staff.

“Staff at all health services which provide maternity services will
be required to undertake intensive training, including one led by the Royal
Women’s Hospital, to help them better identify, address and alert risks during birth,” the Health minister’s statement

“A new state-wide perinatal plan will
be developed”.

Mr Fitzgerald said he had confi dence in his team to provide high quality
maternity services to the local community.

“I am confident that we have the staff, systems and processes in place
to support the delivery of safe and appropriate obstetric care to women in
our region,” he said.

“I would encourage any women that have concerns about any aspect of their care to contact Western District Health
Service direct.”

The WDHS community liaison phone number for WDHS is 5551 8583 and
AHPRA’s phone number is 1300 419 495.