10 Mar 2017
In 2015 the Department of Health and Human Services (the Department) in Victoria was alerted to a cluster of potentially avoidable newborn and stillborn deaths at Bacchus Marsh Hospital (Djerriwarrh Health Services).
This led the Department to commission Dr Stephen Duckett to review of hospital safety and quality assurance in Victoria.
From August 2015, AHPRA began investigating a number of registered health practitioners who practised at Bacchus Marsh Hospital at the time of this tragedy and other matters that have been notified to us. As a risk-based regulator, our priority has been to make sure that any ongoing risk to the public with individual health practitioners has been addressed so patients are safer in the future.
We have now completed a number of investigations into health practitioners who worked at Bacchus Marsh Hospital at that time. For families who have suffered terrible loss, our focus has been on ensuring each investigation is thorough and fair and that they are properly informed about the outcome of an investigation.
In this statement we provide an update on the number of investigations that have been closed and provide information on the range of outcomes that have resulted. Privacy provisions in the National Law limit what we can say about actions taken about individual practitioners.
While our investigations are independent, we have communicated regularly with Djerriwarrh Health Service about the information we need to undertake thorough investigations. Djerriwarrh has informed us of the improvements that the health service has made in areas such as supervision, training and clinical governance. In some cases, practitioners have completed training mandated by the Djerriwarrh Health Service, and this has been sufficient to address the Boards’ concerns about their standards of practice. As a risk-based regulator, our priority has been to make sure that any ongoing risk to the public posed by individual health practitioners has been addressed.
In addition to the investigations into individual health practitioners, we have also worked to improve how we assess and manage notifications as well as how we can contribute to system-wide improvements. This has included working with Victorian health services to increase awareness of mandatory reporting requirements as well as looking at ways we can work with Safer Care Victoria to help detect and respond to concerns about standards and safety. We have also established a regulatory compact with the Department of Health and Human Services which sets out the ways we will share and manage information in the public interest and within the National Law to improve patient safety.
The investigations we have undertaken have been complex. They have involved examining many thousands of pages of clinical records, gathering information to identify the individuals who provided care and establish what happened and what should have happened in each case. We have set up a special team to manage these investigations. We have also sought expert clinical advice to help analyse this information.
Usually, people come to us and tell us about their concerns about specific registered health practitioners. Most of the investigations about Bacchus Marsh Hospital practitioners are different because we have had to start with the medical records and work through them to:
A number of these practitioners no longer work at Djerriwarrh Health Service. This includes five practitioners who have surrendered their registration during the period of AHPRA’s and other investigations. This number includes some practitioners about whom immediate action has been taken. However, surrender of registration does not necessarily mean that investigations are discontinued, or that regulatory action will not be taken.
Of the 96 matters:
Significant failings in clinical governance have previously been identified as contributing to the tragic events which occurred at Bacchus Marsh hospital. Clinical governance refers to the systems, processes and accountabilities which ensure the quality and safety of care in a health service.
Twelve of our investigations involve practitioners who have either significant non-clinical responsibilities or who had supervisor or clinical leadership roles which carried additional responsibilities for oversight of quality and safety. Some of these investigations have been completed.
The table below outlines the outcomes for investigations which have now concluded. Note that some practitioners have been identified as being involved in multiple matters.
If a Board reasonably believes a registered practitioner has behaved in a way that constitutes professional misconduct, the board must refer the matter to the responsible tribunal (in this case VCAT). Where a practitioner is no longer registered (because they have not renewed their registration or have surrendered their registration) the board must make a decision of whether to proceed with a referral to the tribunal. If there is public interest in doing so (because, for example, the board seeks an order that the individual should be prohibited from applying for registration in the future) then the board will continue with the referral.
If a matter is referred to the tribunal, both the existence of the proceedings and the outcome are generally published by the tribunal. A full list of potential outcomes from an investigation is available on the AHPRA website.
Download a PDF of this Media statement - Update on the status of investigations - health practitioners associated with Djerriwarrh Health Services (Bacchus Marsh) - 10 March 2017 (66.3 KB,PDF)