Australian Health Practitioner Regulation Agency - Former Bacchus Marsh midwife given 10 year ban
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Former Bacchus Marsh midwife given 10 year ban

25 Jun 2020

A former Victorian midwife who was employed at Bacchus Marsh Hospital has been reprimanded and banned from practising for 10 years after a tribunal made 11 findings of professional misconduct following a referral by the Nursing and Midwifery Board of Australia.

The Board’s allegations about Mary Little at the Victorian Civil and Administrative Tribunal (the tribunal) hearing included:

• lack of competence in foetal surveillance and lack of recognition of and response to incompetence in others including the Assistant Nurse Unit Manager

• inadequate direct clinical care of two patients

• inadequate clinical review of eight adverse outcomes between 2008 and 2014

• inadequate open disclosure about adverse outcomes in 16 cases between 2008 and 2014; and

• documentation failures.

The tribunal found Mrs Little failed in her delivery of care and oversight in her position as Nurse Unit Manager – Maternity Services, between September 2008 and May 2014. The tribunal found that Mrs Little engaged in professional misconduct in relation to each of the 11 allegations.

Mrs Little admitted all allegations and acknowledged that each allegation constituted professional misconduct. The tribunal reprimanded Mrs Little and disqualified her from applying for registration under the National Law for a period of 10 years.

Mrs Little surrendered her registration in March 2016 and has not practised since then.

NMBA Chair, Associate Professor Lynette Cusack said: ‘Women place their trust in midwives to provide safe care for them and their babies. This is a case of that trust being broken, with tragic consequences. We urge all midwives and nurses to understand their professional responsibility at all levels to provide leadership to ensure the delivery of safe and quality care. As leaders, they must also ensure employees comply with their obligations to provide safe and quality care.’

‘First and foremost our thoughts are with the families affected by the tragic deaths of babies at Bacchus Marsh’, Ahpra CEO Mr Martin Fletcher said.

‘As regulators, our job is to make sure that any ongoing risk to the public posed by individual practitioners has been addressed. This tribunal outcome sends a strong message about the accountability of all registered health practitioners for ensuring all patients are safe.’

The full decision will be published on the Austlii website and the tribunal’s website.


In February 2016, Ahpra and the NMBA launched investigations in relation to 101 matters about the care provided by individual practitioners at the Bacchus Marsh Hospital during the period of October 2011 to February 2013. This followed a cluster of potentially preventable stillbirths and neonatal deaths at the Bacchus Marsh Hospital (Djerriwarrh Health Service).

Forty three registered health practitioners were the subject of concerns in the 101 matters reported (some practitioners were the subject of multiple notifications). All investigations have finalised, with some practitioners awaiting hearing in the Victorian Civil and Administrative Tribunal.

For the 43 registered health practitioners reported, almost half (21 practitioners) had matters which were able to be closed without the need for regulatory action. This includes practitioners who surrendered their registration or who had already undertaken steps towards remediation, which a National Board considers sufficient to manage any ongoing risk to the public. For example, when a practitioner has completed education or training that addresses any gaps identified in their skills or knowledge.

For those practitioners where further action was taken:

• six practitioners were cautioned

• six practitioners had conditions imposed on their registration (including those who were cautioned and had conditions imposed), and

• ten practitioners were referred to a panel hearing or the Victorian Civil and Administrative Tribunal.

Further information about the possible outcomes of a notification can be found on the Ahpra website.

For more information

• Lodge an online enquiry form

• For registration enquiries: 1300 419 495 (within Australia) +61 3 8708 9001 (overseas callers)

• For media enquiries: (03) 8708 9200

Page reviewed 25/06/2020